Poudre Canyon Rehab: Infection Control Lapses - CO
FORT COLLINS, CO - Poudre Canyon Rehabilitation and Nursing, LLC faced multiple safety and infection control violations during a January 22, 2025 state inspection, including failures to properly implement safety protocols, infection prevention measures, and maintain secure access to hazardous areas.
Infection Control Protocols Compromised
The facility was cited for failing to establish an adequate infection prevention and control program, with inspectors documenting two significant breakdowns in safety protocols. The violations centered on enhanced barrier precautions (EBP) - specialized infection control measures designed to prevent the spread of drug-resistant organisms and healthcare-associated infections.
During the inspection, a registered nurse was observed providing wound care to a resident who required enhanced barrier precautions due to a urinary catheter. The nurse entered the room wearing only a mask and gloves, failing to don the required protective gown despite clear signage indicating EBP requirements and readily available protective equipment hanging inside the door.
Enhanced barrier precautions represent a critical line of defense against dangerous healthcare-associated infections. According to CDC guidelines, these measures are essential for residents with indwelling medical devices, wounds, or known colonization with multi-drug resistant organisms. The protective gown serves as a barrier preventing contamination of healthcare workers' clothing, which can then carry infectious agents to other residents.
When questioned, the nurse acknowledged that "she should have put on a gown and did not think about it when entering the room to complete wound care." The facility's infection preventionist confirmed that any resident with chronic wounds, urinary catheters, history of MRSA, ostomies, or feeding tubes qualifies for enhanced barrier precautions.
Ice Contamination Creates Health Risk
A second infection control violation involved unsanitary ice handling practices that could lead to foodborne illness outbreaks. Inspectors observed a resident using her personal cup to scoop ice directly from the communal ice box in the dining room, bypassing proper hygiene protocols.
Ice contamination poses serious health risks in vulnerable populations. Nursing home residents typically have compromised immune systems, making them particularly susceptible to gastrointestinal infections that can spread rapidly through communal facilities. Direct contact between personal containers and communal ice supplies creates multiple pathways for cross-contamination.
The facility's infection preventionist stated that "residents were not allowed to scoop their own ice from the ice boxes" and that staff should assist residents using designated scoops. However, a certified nursing assistant was present during the violation but failed to intervene, indicating a breakdown in staff training or supervision.
Hazardous Areas Left Unsecured
Safety violations included multiple instances where potentially dangerous areas remained accessible to residents. Inspectors documented that a utility room containing computer servers and electrical cables near the dining area was repeatedly left open over several days. The room was observed open on January 13, 14, and 15, with equipment carts and mobility aids placed nearby while the door remained unsecured.
Electrical equipment and exposed cables present serious safety hazards for nursing home residents. Many residents experience cognitive impairment, mobility limitations, or medication side effects that can affect judgment and coordination. Unsecured electrical equipment poses risks of electrocution, while exposed cables create tripping hazards that could result in serious falls.
The maintenance director told inspectors the room "had always had the door open" for ventilation purposes due to heat generated by computer equipment. However, this practice violates basic safety protocols requiring secure access to utility areas.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
POUDRE CANYON REHABILITATION AND NURSING, LLC in FORT COLLINS, CO was cited for violations during a health inspection on January 22, 2025.
During the inspection, a registered nurse was observed providing wound care to a resident who required enhanced barrier precautions due to a urinary catheter.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.