Poudre Canyon Rehabilitation and Nursing, LLC

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#6) of one resident reviewed for accidents and hazards received adequate supervision to prevent an elopement out of 26 sample residents. Resident #6 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance, chronic respiratory failure and traumatic brain injury. Beginning in January 2026, the resident began displaying elopement seeking behavior and was telling staff he wanted to leave the facility. His exit-seeking behaviors escalated, which prompted a review from the physician, who recommended a wanderguard device and expressed serious concerns regarding his safety, poor insight, and impaired judgement. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, sanitary and comfortable homelike environment for five out of five units. Specifically, the facility failed to:-Maintain comfortable temperature levels in residents' rooms and common areas;-Ensure residents' were provided clean linens; -Ensure the staff's dog(s) who visited regularly had the proper vaccinations and health care treatments; and,-Ensure the dog was sufficiently monitored by staff so that the staff could perform their job while ensuring the dog was not creating any safety concerns throughout the building with any resident or visitors in the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#12) of one resident out of 26 sample residents. Specifically, the facility failed to ensure an assessment was completed to determine whether the self-administration of medications was clinically appropriate for Resident #12.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide reasonable accommodations necessary to accommodate mobility and accessibility in the resident's environment for one (#8) of three residents reviewed for accommodation of needs out of 26 sample residents. Specifically, the facility failed to ensure Resident #1, who relied on bedside bed rails and transfer poles for mobility, had appropriate accommodations after the facility removed all bedside bed rails and transfer poles from the resident's room.

Inspectors wroteBased on record review and interviews the facility failed to thoroughly investigate in order to prevent further potential abuse after a resident-to-resident physical altercation for one of three allegations of abuse. Specifically the facility failed to:-Complete a thorough investigation and maintain documentation of efforts to determine a root cause of the resident's abusive actions to prevent repeated resident-to-resident physical abuse incident by Resident #6 towards Resident #15; -Assess Resident #6's behavior to determine the possible root cause of why the resident suddenly presented with physically aggressive behavior towards another resident when he had never been aggressive towards another resident in the past; -Develop and implement care plan interventions to prevent Resident #6 from engaging in a physically aggressive manner towards another resident; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice for two (#12 and #4) of two residents reviewed for respiratory services out of 26 sample residents. Specifically, the facility failed to:-Ensure there was a physician's order in place for Resident #12's respiratory therapy, bilevel positive airway pressure (BIPAP) machine and routine cleaning of the BiPAP;-Ensure there was a physician's order in place for the maintenance, cleaning and storage of Resident #4's continuous positive airway pressure (CPAP);-Ensure Resident #12 and Resident #4's comprehensive care plan had a care focus for the use of the BiPAP and CPAP treatment; and, -Ensure Resident #12 BiPAP and Resident #4's CPAP supplies were stored in a sanitary manner.

Inspectors wrote-Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety throughout the facility. Specifically, the facility failed to ensure meal trays were promptly removed from the residents' rooms to ensure food was not available to residents at unsafe temperatures.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#10) of five residents reviewed for medication management were free from significant medication errors out of 22 sample residents. Resident #10 was admitted to the facility on [DATE] with a diagnosis of dementia. On 4/29/25 a nurse administered Resident #10 Lisinopril (used to treat high blood pressure), Metformin (used to treat diabetes), Seroquel (used to treat mental health conditions) and Ramelteon (used to treat insomnia). The resident began to experience severe hypotension (a dangerously low blood pressure) and was sent to the hospital. The resident received intravenous fluids and was monitored. Specifically, the facility failed to ensure Resident #10 did not receive another resident's (Resident #20) medications.

Inspectors wroteIV. Failed to prevent two incidents of physical abuse of Resident #4 by Resident #22 A. First incident of physical abuse of Resident #4 by Resident #22 on 5/1/25 at 1:10 a.m. An incident report, dated 5/1/25 at 1:10 a.m. and written by LPN #6, related to an unwitnessed physical aggression, revealed LPN #6 and a CNA were on duty and heard yelling from down the hall and went to investigate. Resident #22 was observed walking out of Resident #4's room and began walking down Hall 200. The CNA went to check on Resident #22, while LPN #6 spoke with Resident #4 to ensure his safety. Resident #4 said Resident #22 hit him on his cheek. Resident #4 said that Resident #22 told him that the belongings in Resident #4's room were his (Resident #22's) and they were not. Resident #4 said he told Resident #22 the room was his room and then Resident #22 hit him on the cheek. [...]

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of sexual and physical abuse to the State Survey and Certification Agency in accordance with state law for four of seven alleged abuse violations. Specifically, the facility failed to: -Submit a final report of the facility's investigation of two separate physical abuse allegations involving Resident #5 and Resident #4 to the State Agency within five calendar days of the incidents; -Submit a final report of the facility's investigation of a physical abuse allegation involving Resident #7 and Resident #8 to the State Agency within five calendar days of the incident; and, -Submit a final report of the facility's investigation of a sexual abuse allegation involving Resident #9 and a facility visitor to the State Agency within five calendar days of the incident.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for two of seven abuse allegations. Specifically, the facility failed to: -Thoroughly investigate an allegation of sexual abuse on 4/12/25 for Resident #9 in order to prevent a second incident from occurring on 4/23/25; and, -Thoroughly investigate an allegation of physical abuse between Resident #7 and Resident #8. I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised 4/11/25, was provided by the director of nursing (DON) on 5/6/26 at 12:22 p.m. It read in pertinent part, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include investigating different types of alleged violations; [...]

Inspectors wroteIII. The facility failed to ensure Residents #168, #169, and #25 were free from physical abuse from Resident #43. Resident #43 had a history of physical altercations. He hit Resident #168, pushed Resident #169, and grabbed and shoved Resident #25. A. Facility policy and procedure The Abuse policy and procedure, revised on 6/11/24, was provided by the regional director of quality and compliance (RDQC) on 1/22/25 at 4:55 p.m. It documented in pertinent part, Every resident has the right to be free from all forms of abuse: verbal, sexual, physical, mental, neglect, corporal punishment and involuntary seclusion. B. Incident on 5/13/24 between Resident #43 and Resident #168 1. Facility investigation A 5/13/24 abuse investigation documented there was a witnessed physical altercation between two residents. The residents were separated, assessed, and placed on one-to-one monitoring. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide adequate supervision to keep residents free from accidents/hazards for two (#23 and #28) of five residents reviewed for accidents out of 38 sample residents. Resident #23, who was admitted on [DATE], required the use of a Hoyer lift (mechanical lift) and two-person staff assistance for transfers. Interviews during the survey revealed the resident had erratic body movements due to her diagnosis of anoxic brain damage (a condition caused by the brain being deprived of oxygen and leading to brain cell death). On 1/12/25, Resident #23 was being transferred by two staff members and hit her head on the bar of the Hoyer lift. The resident sustained a laceration to her head. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to serve food that was palatable and attractive. Specifically, the facility failed to ensure that the resident's food was palatable in taste, texture and appearance.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse that rose to the level of immediate jeopardy.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for two (#167 and #64) of five residents reviewed for quality of care out of 38 sample residents. Specifically, the facility failed to: -Ensure Resident #167's physician was notified in a timely manner when attempts to start an intravenous (IV) line were unsuccessful and staff could not administer IV fluids per the physician orders; and, -Ensure Resident #64's laboratory (lab) blood work was addressed by the resident's physician in a timely manner.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to use a person-centered approach when determining the use of bed rails for one resident (#1) out of 38 sample residents. Specifically, for Resident #1, the facility failed to: -Assess the resident for the safe use of bed rails, including assessment for risk of entrapment prior to installing the bed rails; -Create and document a personal care plan for the safe use of bed rails; -Obtain consent from the resident and/or the resident's representative before bed rails installation, including informing them of the risks versus benefits of bed rails; -Obtain a physician's order for the bed rails; and, -Conduct quarterly assessments of the bed rails to evaluate their continued need and safety.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication administration error was not greater than five percent. Specifically, the facility's medication administration error rate was 8% (percent), or two errors out of 25 opportunities for error.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for two (#18 and #46) of two residents reviewed for medications errors out of 38 sample residents. Specifically, the facility failed to ensure that Resident #18 and Resident #46 were administered the correct dose of insulin by properly priming the insulin pen before insulin administration.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in one of two medication carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure expired medications were removed from the medication cart; and, -Ensure all medications were labeled with resident information.

Inspectors wroteBased on observation, record review and interviews, the facility failed to establish an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and healthcare associated infections. Specifically, the facility failed to: -Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP); and, -Ensure sanitary conditions related to the ice box

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional and comfortable environment on two of five units. Specifically, the facility failed to: -Ensure the utility door room near the dining room, between the 300 and 400 units, was closed and not accessible to residents; and, -Ensure room [ROOM NUMBER] on the 500 unit, which was under construction, was not accessible to residents.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to: -Maintain kitchen sanitation and prevent potential cross contamination during the meal preparation and meal delivery; and, -Label, date and discard expired foods appropriately.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to: -Include the email address of the State Survey Agency so a resident may file a care complaint; and, -Post the information in a manner accessible and understandable to all residents.

Inspectors wroteBased on observations, and interviews, the facility failed to ensure medication error rate was not greater than five percent. Specifically, the facility's medication error rate was 12 percent with three errors out of 25 opportunities.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the kitchen provided food that accommodated resident preferences for one (#22) of five residents of 36 sample residents. Specifically, the facility failed to ensure Resident #22 was receiving their menu choices.

Inspectors wroteBased on record review and observations, the facility failed to ensure one (#19) of five out of 36 sample residents received food and fluids prepared in a form designed to meet his or her needs per speech therapy recommendation, physician orders and the resident's care plan. Specifically, the facility failed to provide meals to Resident #19 according to the prescribed diet order.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for two residents (#45 and #38) of five out of 36 sample residents. Specifically, the facility failed to: -Ensure resident refrigerator temperatures were monitored for refrigerated food storage; and, -Provide the resident and/or resident representative with information on their right to store food and the process for doing so.

Inspectors wroteBased on observations and interviews, the facility failed to post notice of the most recent survey of the facility conducted by Federal or State surveyors in a place readily accessible to residents, and family members and legal representatives of residents. Specifically, the facility failed to post notice of the availability of the State survey results in areas of the facility that were prominent and accessible to the public.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one resident (#32) had the right to a dignified existence out of 45 sample residents. Specifically, the facility failed to ensure Resident #32 experienced a dignified living experience by ensuring meals were served timely. Resident #32 said he felt frustrated, humiliated, sad and dehumanized by having to wait over 30 minutes for his meals when his tablemates had already been served, because he required staff assistance. The observations conducted during the survey process showed Resident #32 was the last individual to be served his meal in the dining room. He waited 27 minutes to receive his lunch meal on 6/13/22, after his tablemates had already been served. During this observation, the resident was yelling multiple times asking for his meal and became angry when his food did not arrive timely.

Inspectors wroteBased on record review and interviews, the facility failed to ensure four (#62, #58, #27, and #6) of seven residents reviewed for accidents out of 45 sample residents remained as free from accident hazards as possible. Resident #62 sustained five falls in the facility within a six month period. The facility identified the resident's numerous fall risks (history of falls, cognitive impairment) but failed to develop, communicate and implement effective interventions based on thorough investigations after each fall, in order to minimize her risks and keep her safe from injury. The resident's fourth fall on 4/8/22 resulted in a clavicle fracture, and the fifth fall on 4/14/22 in hematoma and laceration of her forehead. Additionally, the facility failed to: -Ensure effective interventions were evaluated and put into place after Resident #27 had sustained five falls; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to: -Ensure residents were served the correct diets; and, -Follow correct portion sizes to ensure adequate nutrition was provided to the residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure food was labeled and dated; -Ensure the kitchen was clean and sanitary; and, -Ensure holding temperatures of food were within the correct range.

Inspectors wroteBased on interviews and record review, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow up with residents ' concerns regarding meals that were brought up by the resident council and food committee.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#25) of four residents reviewed for abuse out of 45 sample residents. Specifically, the facility failed to report incidents of alleged abuse to the State Agency made by Resident #25.

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, appearance and temperature.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19. Specifically, the facility failed to initiate isolation precautions timely to control a scabies outbreak.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two (#63 and #60) out of 45 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide resolutions to food concerns voiced by Resident #63 and Resident #60.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#38) of four out of 45 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #38 was kept free from abuse by Resident #62.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure three (#32 ,#9 and #39) of five residents reviewed out of 45 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Resident #32, Resident #9 and Resident #39 were assisted with personal hygiene including nail care and facial hair. I. Resident #32 A. Resident status Resident #32, younger than 65, was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), the diagnoses included epilepsy (seizure disorder), speech disturbances, lack of coordination, dysphagia (swallowing difficulty), need for assistance with personal care, and gastro-esophageal reflux disease (GERD). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#21) of two residents reviewed for visual problems out of 45 sample residents. Specifically, the facility failed to investigate Resident #21's broken glasses and fix them timely.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#63 and #42) of three out of 45 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Specifically, the facility failed to: -Ensure Resident #63 was served a therapeutic diet to meet her nutritional needs; and, -Ensure Resident #42 was re-weighed in a timely manner after a significant weight gain.

Inspectors wroteBased on interviews, record review and observations, the facility failed to assist a resident to obtain routine or emergency dental services, as needed, for one (#58) out of two of 45 sample residents. Specifically, Resident #58 lost his dentures at the hospital and the facility did not assist the resident in finding the lost dentures or obtaining new dentures.