nursing home in Windsor, CO
Columbine Commons Health and Rehab LLC
1475 Main St, Windsor, CO 80550 · (970) 449-5540
★★★★★5
Much above average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★5
- Staffing★★★★★3
- Quality measures★★★★★3
- CMS high performer
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Columbine Commons Health and Rehab LLC at a glance
Columbine Commons Health and Rehab LLC is a 60-bed for-profit nursing home in Windsor, Colorado (Weld County).
CMS gives it 5 out of 5 stars on its overall star rating, better than the Colorado average of 3.2.
Residents receive about 4 hours of nursing care per day (0.9 of them from registered nurses), better than the state average of 3.7 hours.
Its most recent standard health inspection (April 17, 2025) found 2 health citations. The Colorado average is 8.7.
It has not received a federal fine in the past three years.
Nursing staff turnover is 92% per year (state average 47.1%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Limited Liability Company
- Beds
- 60
- Certified for
- Medicare
- Medicare-certified since
- February 13, 2014
- Continuing care retirement community
- Yes
- Resident/family council
- Resident
- County
- Weld County
- CMS Certification Number
- 065410
Ratings
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 5 / 5 | 3.2 / 5 | 3 / 5 | Better |
| Health inspection rating ⓘ (higher is better) | 5 / 5 | 2.7 / 5 | 2.8 / 5 | Better |
| Staffing rating ⓘ (higher is better) | 3 / 5 | 3.2 / 5 | 2.9 / 5 | Average |
| Quality measures rating ⓘ (higher is better) | 3 / 5 | 4.1 / 5 | 3.6 / 5 | Worse |
| Long-stay quality rating (higher is better) | 2 / 5 | 4.1 / 5 | 3.8 / 5 | Worse |
| Short-stay (rehab) quality rating (higher is better) | 3 / 5 | 4 / 5 | 3.3 / 5 | Average |
Staffing
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 4.02 hrs | 3.72 hrs | 3.86 hrs | Average |
| Registered nurse hours per resident per day (higher is better) | 0.90 hrs | 0.82 hrs | 0.69 hrs | Better |
| Nurse aide hours per resident per day (higher is better) | 2.29 hrs | 2.21 hrs | 2.32 hrs | Average |
| Weekend nurse staff hours per resident per day (higher is better) | 3.66 hrs | 3.29 hrs | 3.42 hrs | Better |
| Nursing staff turnover (yearly) (lower is better) | 92% | 47.1% | 45.8% | Worse |
| Registered nurse turnover (yearly) (lower is better) | 96.3% | 44.6% | 42.9% | Worse |
| Administrators who left in the past year (lower is better) | 1 | 0 | 1 | Worse |
Inspections
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 2 | 9 | 9 | Better |
| Citations from complaint investigations (latest cycle) (lower is better) | 0 | 2 | 3 | Better |
| Weighted health inspection score ⓘ (lower is better) | 20 | 74 | 80.6 | Better |
Penalties
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 0 | 1 | 1 | Better |
| Total fines in the past 3 years (lower is better) | $0 | $22,802 | $30,972 | Better |
| All federal penalties in the past 3 years (lower is better) | 0 | 1 | 1 | Better |
Size
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 60 | 94 | 107 | |
| Average residents per day | 58 | 75 | 86 | |
| Occupancy | 96.2% | 80.7% | 80.9% |
Long-stay residents
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 4.1% | 3.4% | 3.2% | Worse |
| Long-stay residents with pressure ulcers (lower is better) | 5.4% | 3.4% | 4.6% | Worse |
| Long-stay residents given antipsychotic medication (lower is better) | 26.4% | 20% | 15.4% | Worse |
| Long-stay residents with a urinary tract infection (lower is better) | 8% | 1.4% | 1.6% | Worse |
| Long-stay residents with a catheter left in the bladder (lower is better) | 0% | 0.6% | 0.8% | Better |
| Long-stay residents needing more help with daily activities (lower is better) | 20% | 13.4% | 13.9% | Worse |
| Long-stay residents whose walking worsened (lower is better) | 28.9% | 13.3% | 14.1% | Worse |
| Long-stay residents who lose too much weight (lower is better) | 2.7% | 4.7% | 5.2% | Better |
| Long-stay residents with depressive symptoms (lower is better) | 1.4% | 8.8% | 12.8% | Better |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0.1% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 14.5% | 11.5% | 19.5% | Better |
| Long-stay residents with new or worse incontinence (lower is better) | 30.5% | 21.2% | 19% | Worse |
| Long-stay residents given a flu vaccine (higher is better) | 100% | 94.7% | 95.5% | Average |
| Long-stay residents given a pneumonia vaccine (higher is better) | 96.6% | 93.5% | 93.6% | Average |
Short-stay residents
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 3.9% | 1.6% | 1.6% | Worse |
| Short-stay residents given a flu vaccine (higher is better) | 98.8% | 75.6% | 79.8% | Better |
| Short-stay residents given a pneumonia vaccine (higher is better) | 87.5% | 76.4% | 82% | Better |
Inspection citations
State inspectors cited this home for 7 health deficiencies and 26 fire safety deficiencies in the inspection records CMS currently publishes. None were rated as causing actual harm to residents.
| Date | Citation | Severity | Status |
|---|---|---|---|
| April 17, 2025 Fire safety | Have properly located and lighted "Exit" signs. Egress Deficiencies · Tag K0293 | F Potential harm, widespread | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | F Potential harm, widespread | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Tag K0521 | F Potential harm, widespread | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Tag K0355 | F Potential harm, widespread | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected August 23, 2025 |
| April 17, 2025 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | F Potential harm, widespread | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Tag K0291 | F Potential harm, widespread | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Tag K0741 | F Potential harm, widespread | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0923 | D Potential harm, isolated | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Tag K0222 | D Potential harm, isolated | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Install proper backup exit lighting. Egress Deficiencies · Tag K0281 | D Potential harm, isolated | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Tag K0321 | D Potential harm, isolated | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | D Potential harm, isolated | Corrected July 1, 2025 |
| April 17, 2025 Fire safety | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Tag K0374 | D Potential harm, isolated | Corrected July 1, 2025 |
| April 17, 2025 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected May 9, 2025 |
| April 17, 2025 Standard | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | D Potential harm, isolated | Corrected May 9, 2025 |
| October 12, 2023 Fire safety | Have restrictions on the use of highly flammable decorations. Miscellaneous Deficiencies · Tag K0753 | D Potential harm, isolated | Corrected November 6, 2023 |
| October 12, 2023 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected October 25, 2023 |
| October 12, 2023 Standard | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Tag F0849 | D Potential harm, isolated | Corrected October 25, 2023 |
| October 12, 2023 Standard | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Tag F0678 | D Potential harm, isolated | Corrected October 20, 2023 |
| October 12, 2023 Standard | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · Tag F0761 | D Potential harm, isolated | Corrected October 25, 2023 |
| July 14, 2022 Fire safety | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Tag K0291 | F Potential harm, widespread | Corrected September 4, 2022 |
| July 14, 2022 Fire safety | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Tag K0211 | F Potential harm, widespread | Corrected September 4, 2022 |
| July 14, 2022 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected September 4, 2022 |
| July 14, 2022 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | F Potential harm, widespread | Corrected September 4, 2022 |
| July 14, 2022 Fire safety | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Tag K0521 | F Potential harm, widespread | Corrected September 4, 2022 |
| July 14, 2022 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected September 4, 2022 |
| July 14, 2022 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | F Potential harm, widespread | Corrected September 4, 2022 |
| July 14, 2022 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | E Potential harm, pattern | Corrected September 4, 2022 |
| July 14, 2022 Fire safety | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Tag K0511 | D Potential harm, isolated | Corrected September 4, 2022 |
| July 14, 2022 Fire safety | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Tag K0741 | D Potential harm, isolated | Corrected September 4, 2022 |
| July 14, 2022 Standard | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Tag F0695 | D Potential harm, isolated | Corrected August 31, 2022 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports no federal fines or payment denials in the past three years.
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| ownership data not available |
Other nursing homes near Columbine Commons Health and Rehab LLC
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★★★★★5Much above averageCreekside Village Rehabilitation and Nursing LLC
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★★★★★1Much below averageRehabilitation and Nursing Center of the Rockies
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Frequently asked questions
What is Columbine Commons Health and Rehab LLC's rating?
Columbine Commons Health and Rehab LLC has 5 out of 5 stars on the CMS overall star rating. The average for Colorado nursing homes is 3.2 stars.
How many inspection citations did Columbine Commons Health and Rehab LLC receive?
Its most recent standard health inspection found 2 citations, compared with a Colorado average of 8.7. Every citation is listed on this page with its severity.
Does Columbine Commons Health and Rehab LLC accept Medicare and Medicaid?
CMS lists it as certified for: Medicare. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Columbine Commons Health and Rehab LLC?
It is for profit - limited liability company. The ownership section on this page lists the owners and managers reported to CMS.
Where is Columbine Commons Health and Rehab LLC and how do I contact it?
Columbine Commons Health and Rehab LLC is at 1475 Main St, Windsor, CO 80550. Phone: (970) 449-5540.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.