Poudre Canyon Rehab: Sexual Abuse Investigation Failures - CO
Despite determining the resident could not consent to sexual contact, Poudre Canyon Rehabilitation and Nursing failed to implement adequate protections between the two incidents, according to federal inspectors who cited the facility for abuse violations in May.
The resident, identified as a woman under 65 with anoxic brain damage from a previous accident, cannot communicate effectively or make decisions about intimate contact. Her boyfriend had been with her for several years before the brain injury that left her severely cognitively impaired.
The first incident occurred on Saturday, April 12, when a nursing assistant entered the woman's room and found her boyfriend touching her inappropriately. The resident, who is non-verbal, was screaming. The assistant immediately moved them to a common area for monitoring and reported the incident to nursing staff.
But the facility's investigation was incomplete. Inspectors found no evidence that staff interviewed the witnessing assistant about what she specifically observed. The facility failed to interview the boyfriend. Most critically, administrators put no immediate restrictions in place to prevent him from returning.
The nursing home administrator waited until Monday, April 14, to contact the resident's parents for the boyfriend's contact information. "He said he thought the resident was safe and he did not need to contact the parents for the boyfriend's contact information until the Monday following the allegation," according to the inspection report.
On April 14, an interdisciplinary team determined the resident "could not make or express her desire to engage in sexual intimacy with others" due to her inability to communicate effectively. Yet the boyfriend continued visiting.
The second incident occurred on April 23. The administrator knew the boyfriend planned to visit around 8:30 a.m. and went into a meeting from 9:15 to 9:45 a.m. with the director of nursing. When the meeting ended, the boyfriend had not arrived. The administrator briefly left the facility. Around 10 a.m., the boyfriend was observed with the resident in a common area with no staff assigned to monitor the visit.
A nursing assistant later reported seeing the boyfriend with his hands between the resident's legs, moving up and down. She notified nursing staff and the administrator that day. The boyfriend left after a conversation with the administrator.
The resident's parents had continued encouraging the relationship despite their daughter's condition. They provided transportation for weekend visits and preferred that facility staff manage the interactions rather than staying to supervise themselves.
Staff members had witnessed concerning behavior before. CNA #6 told inspectors that in February 2025, she saw the boyfriend touch the resident's breast "down the front of the resident's shirt" during toileting care. She reported it to a nurse and was told the resident's parents had been notified and "said it was okay."
"CNA #6 said she thought it was weird because Resident #9 did not have the capacity to consent," the inspection report states. "CNA #6 said she heard other staff members made complaints about the boyfriend and what they saw but staff did not see any changes in regards to the boyfriend's visits until the alleged incident in April 2025."
Another assistant, CNA #5, had observed the boyfriend touching the resident's thighs, kissing her forehead, and trying to close the door during visits. She said she only saw him visit in the resident's room, not in common areas as facility policy later required.
The facility's care plan, revised in December 2024, specified that visits with the boyfriend should happen in community areas and that he should not be alone with the resident without staff or her parents present. However, this intervention was not implemented until April 18, six days after the first alleged incident.
The director of nursing told inspectors she was unaware of the February incident until CNA #6 mentioned it during the survey in May. The facility began investigating that allegation only on May 8, more than three months after it occurred.
Communication among staff about visitor restrictions proved inadequate. When inspectors interviewed employees in May, they found inconsistent knowledge about who was prohibited from visiting. Some staff said they relied on pictures posted at the nurses' station, but no photo of the boyfriend was available. Others said they checked care plans or communication boards in the electronic medical record system.
The facility didn't prohibit the boyfriend's visits entirely until May 13, following a recommendation from the ombudsman. Even then, education about the restriction was incomplete. The director of nursing said all clinical staff received education on May 12, but the administrator acknowledged he provided no education to non-clinical staff who could unlock doors for visitors.
A care conference held during the inspection on May 15 included the resident, her parents, facility administrators, police, Adult Protective Services, and the ombudsman. The director of nursing said three different nursing assistants had witnessed the boyfriend touching the resident inappropriately.
A police detective expressed concerns that the resident lacked the capability for a sexual relationship and could not consent. An Adult Protective Services representative attended because of questions about the resident's ability to understand intimate relationships.
Despite these concerns, the resident's mother and facility administrators agreed the boyfriend could resume supervised visits with the administrator or director of nursing present. The director of nursing said the facility would document the resident's reactions to determine when she wanted the boyfriend present and when she didn't.
The administrator later told inspectors he was "unable to substantiate the 2/1/25 and 4/23/25 sexual allegations because the boyfriend was important to Resident #9's quality of life."
Beyond the investigation failures, the facility submitted final reports to state authorities late for four separate abuse allegations between March and April. The administrator acknowledged the investigations were completed on time but admitted to "poor timing skills" in submitting required reports, some arriving weeks after deadlines.
The resident remains at the facility. Her parents continue to believe the relationship benefits their daughter, despite her inability to communicate whether she wants physical contact or visits from her former boyfriend.
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 2025-05-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
POUDRE CANYON REHABILITATION AND NURSING, LLC in FORT COLLINS, CO was cited for abuse-related violations during a health inspection on May 15, 2025.
Her boyfriend had been with her for several years before the brain injury that left her severely cognitively impaired.
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.