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.
Construction Zone Accessible to Residents
Perhaps most concerning, inspectors found an unlocked room under construction on the facility's 500 unit that contained mechanical tools including drills, nails, and screws. The room also featured exposed plumbing where drywall panels had been removed, creating multiple safety hazards.
Construction tools and exposed infrastructure create immediate dangers for nursing home residents. Sharp tools, loose hardware, and exposed plumbing present risks of cuts, puncture wounds, and falls. The combination of cognitive impairment common in nursing home populations and readily accessible dangerous materials represents a significant liability.
The nursing home administrator expressed surprise about the accessible construction materials, stating she "was not aware that room had tools in it and was still accessible to residents." This suggests a breakdown in communication between administrative staff and maintenance personnel regarding ongoing construction projects.
Medical Context and Health Implications
These violations collectively represent failures in fundamental patient safety protocols that form the backbone of quality nursing home care. Infection control measures prevent the spread of life-threatening diseases among vulnerable residents, while environmental safety protocols protect against injuries that could prove catastrophic for frail elderly patients.
The healthcare-associated infection prevention failure is particularly significant. Multi-drug resistant organisms spread rapidly in congregate care settings and can cause severe, sometimes fatal infections in elderly residents with compromised immune systems. Enhanced barrier precautions, when properly implemented, reduce transmission rates by up to 50% according to clinical studies.
Environmental hazards pose compounding risks for nursing home residents. Falls represent the leading cause of injury-related death among adults over 65, and nursing home residents face elevated fall risks due to medications, mobility limitations, and cognitive impairment. Unsecured hazardous areas exponentially increase these baseline risks.
The facility's infection prevention and control program policy references CDC and OSHA standards, indicating awareness of proper protocols. However, the observed violations suggest gaps between written policies and actual implementation, pointing to potential deficiencies in staff training, supervision, or compliance monitoring.
Quality Assurance Oversight Issues
The inspection also revealed that the facility's Quality Assurance and Performance Improvement (QAPI) program had not identified these safety issues through internal monitoring. The nursing home administrator acknowledged that environmental safety concerns and infection control compliance "have not been identified as a problem" in monthly QAPI meetings.
Effective quality assurance programs serve as early warning systems for patient safety issues. Regular environmental rounds, infection control audits, and staff competency assessments should identify and address these types of violations before they impact patient care or regulatory compliance.
Additional Issues Identified
The inspection documented additional concerns including inadequate management of residents with behavioral issues. One resident with a documented history of sexually inappropriate behavior was involved in an incident on January 1, 2025, though this history had not been adequately addressed through the facility's quality improvement processes.
The medical director interviewed during the inspection indicated he was unaware of this resident's behavioral history until the recent incident, suggesting communication gaps between clinical and administrative staff regarding high-risk residents.
These violations demonstrate the interconnected nature of nursing home safety systems, where breakdowns in one area often signal broader issues with staff training, supervision, and quality oversight. The facility received citations at minimal harm levels, indicating inspectors found no evidence that residents were actually injured by these safety lapses, though the potential for harm was clearly documented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Poudre Canyon Rehabilitation and Nursing, LLC from 2025-01-22 including all violations, facility responses, and corrective action plans.
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