Columbine West Health And Rehab Llc
COLUMBINE WEST HEALTH AND REHAB LLC in FORT COLLINS, CO — inspection on February 27, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F600:
The facility failed to ensure residents were protected from resident-to-resident sexual abuse.
The facility's failure to protect residents from resident-to-resident sexual abuse put residents in a situation where a serious outcome occurred and created an immediate jeopardy situation.
IV.
Staff interviews
The NHA was interviewed on 2/27/25 at 6:05 p.m.
The NHA said the QAPI committee consisted of the medical director, the director of nursing (DON), the staffing coordinator, the medical records director, the infection preventionist, the wound care/restorative nurse, the dietician, the pharmacist and the NHA.
The NHA said the QAPI committee met monthly and would discuss any concerns that had been identified from current issues in the facility, such as events/occurrences and infections.
The NHA said the facility did not have a PIP for abuse in place since they were put back into compliance from the last recertification survey (April 2024).
-The facility had not previously identified any concerns related to abuse, despite the facility being cited for abuse on their last recertification in April 2024.
065245
F-F744 - failure to ensure a resident diagnosed with dementia received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
065245
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 065245 B.
Wing 02/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Columbine West Health & Rehab Facility 940 Worthington Cir Fort Collins, CO 80526
The facility failed to prevent Resident #2 from grabbing Resident #1's breast on 2/5/25.
The facility's response to the incident on 2/5/25 was one-to-one supervision of Resident #2 until Resident #2's medical provider could see him.
Once the provider saw him and ordered a medication change, one-to-one supervision was lifted on 2/7/25 at 9:30 a.m.
However, based on interviews and observations, staff were not aware of Resident #2's sexually inappropriate behavior and left Resident #2 alone with female residents.
Resident #4, who was admitted to the facility on [DATE], had a history of sexual behavior toward female staff. On 8/8/24, Resident #4 was observed by a staff member rubbing Resident #3's left breast.
The resident's care plan, initiated on 8/8/24, revealed the resident was to sit next to other male residents in group settings to mitigate risk of inappropriate expressions towards other residents.
However, on 2/26/25, Resident #4 was observed sitting at the nurses' station within arm's reach of a female resident.
Staff interviews on 2/25/25 revealed that staff were unaware of the resident's inappropriate behavior and the intervention not to place him next to female residents.
The facility's failure to inform and educate staff on Resident #2 and Resident #4's sexually inappropriate behaviors, monitor the residents' behaviors, and implement planned interventions created a reasonable expectation, absent immediate correction, that an adverse outcome resulting in serious harm could occur.
On 2/26/25 at 2:45 p.m., the nursing home administrator (NHA) was notified that the facility's failure to protect and promote an environment free from resident-to-resident sexual abuse created an immediate jeopardy situation.
B.
Facility plan to remove immediate jeopardy
On 2/27/25 at 10:18 a.m., the facility submitted a plan to remove the immediate jeopardy.
The plan read:
Immediate actions:
Nursing home administrator (NHA) assigned a one-to-one staff member to ensure that Resident #1 and other residents were protected from Resident #2.
The one-to-one supervision will continue until 2/27/25 then additional staff will be added to the schedule on all shifts indefinitely for the secured unit.
This will help ensure that all residents on the secured unit will be safe.
065245
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 065245 B.
Wing 02/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Columbine West Health & Rehab Facility 940 Worthington Cir Fort Collins, CO 80526