Columbine Commons Health and Rehab LLC
1475 Main St, Windsor, CO 80550
Columbine Commons Health and Rehab LLC is a nursing home in Windsor, Colorado. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating5 of 5
- Last standard health inspectionApril 17, 2025 (1 year ago)
- Health citations since July 14, 20227 (Colorado average 25)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
Get an email when CMS publishes something new about this home
One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
Email alerts for this home open soon.
CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 8, 2026
Ownership
CMS no longer lists a chain for this home.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
CMS update of June 24, 2026
Name
CMS lists a new legal business name for this home.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.5 to 4.0 hours per resident per day.
CMS update of February 25, 2026
Staffing
Total nurse staffing reported to CMS went from 5.2 to 4.5 hours per resident per day.
CMS update of January 14, 2026
Name
CMS lists a new name for this home. It was COLUMBINE COMMONS HEALTH & REHAB LLC.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
Health inspection on April 17, 2025
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 9, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on May 9, 2025.
Fire safety inspection on April 17, 2025
15 citationsCMS lists this as a standard inspection.
Show the 15 citations
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on July 1, 2025.
CMS has cited this home for K0291 2 times since 2022.
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on July 1, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on July 1, 2025.
CMS has cited this home for K0345 2 times since 2022.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 23, 2025.
CMS has cited this home for K0353 2 times since 2022.
Citation K0355. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on July 1, 2025.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on July 1, 2025.
CMS has cited this home for K0521 2 times since 2022.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on July 1, 2025.
CMS has cited this home for K0712 2 times since 2022.
Citation K0741. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on July 1, 2025.
CMS has cited this home for K0741 2 times since 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 1, 2025.
CMS has cited this home for K0918 2 times since 2022.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 1, 2025.
Citation K0281. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install proper backup exit lighting.
CMS lists it as corrected on July 1, 2025.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on July 1, 2025.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on July 1, 2025.
CMS has cited this home for K0324 2 times since 2022.
Citation K0374. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on July 1, 2025.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on July 1, 2025.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Name
CMS lists a new name for this home. It was COLUMBINE COMMONS HEALTH AND REHAB LLC.
Ownership
CMS lists this home under a new chain.
Health inspection on October 12, 2023
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 25, 2023.
Citation F0678. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
CMS lists it as corrected on October 20, 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 25, 2023.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 25, 2023.
Fire safety inspection on October 12, 2023
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0753. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on November 6, 2023.
Health inspection on July 14, 2022
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on August 31, 2022.
Fire safety inspection on July 14, 2022
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation K0211. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on September 4, 2022.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on September 4, 2022.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on September 4, 2022.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 4, 2022.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on September 4, 2022.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on September 4, 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on September 4, 2022.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on September 4, 2022.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on September 4, 2022.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on September 4, 2022.
CMS star ratings
- 5 of 5CMS overall star rating
- 5 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (970) 449-5540
- Last standard health inspection
- April 17, 2025 (1 year ago)
- Certified beds
- 60
- Residents per day, on average
- 57.1
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Legal Business Name Not Available
- Chain
- Not listed by CMS
- Takes part in
- Medicare
Fewer health citations than the Colorado average (7 vs 25).
Questions
When was Columbine Commons Health and Rehab LLC last inspected?
CMS lists April 17, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Columbine Commons Health and Rehab LLC have?
CMS lists 7 health citations since July 14, 2022. CMS also calls these deficiencies.
Has Columbine Commons Health and Rehab LLC been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Columbine Commons Health and Rehab LLC?
Its CMS overall star rating is 5 of 5.
Is Columbine Commons Health and Rehab LLC a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.