Poudre Canyon Rehabilitation And Nursing, Llc

F-F600 was cited at K level scope and severity, pattern, immediate jeopardy to residents health and safety. Failure to monitor sexually inappropriate behavior for the resident with a history of such behaviors.

F-F759 was cited at a D level scope and severity, isolated, no actual harm with potential for more than minimal harm.

II. Staff interviews

The nursing home administrator (NHA) was interviewed on 1/15/25 at 5:30 p.m. The NHA said Resident #50 was admitted to the facility prior to change of ownership. She said the resident's history of sexually inappropriate behavior was mentioned in his medical records, however he did not display any inappropriate behaviors until the incident on 1/1/25. She said the facility reviewed all of the residents who might have had a history of sexually inappropriate behaviors to ensure proper interventions were put in place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 065166 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065166 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poudre Canyon Rehabilitation and Nursing, LLC 1000 S Lemay Ave Fort Collins, CO 80524

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 The medical director (MD) was interviewed on 1/16/25 at 9:50 a.m. The MD said he was not aware that Resident #50 had a history of sexually inappropriate behaviors. He said it was brought to his attention this Level of Harm - Minimal harm or week. He said primary care and mental health providers were involved in identifying the best course of potential for actual harm treatment for this resident.

Residents Affected - Some The NHA was interviewed a second time on 1/22/25 at 5:30 p.m. The NHA said QAPI meetings were conducted monthly. She said sexually inappropriate behaviors and Resident #50 were not brought up in the meetings and have not been identified as a problem.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 065166 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065166 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poudre Canyon Rehabilitation and Nursing, LLC 1000 S Lemay Ave Fort Collins, CO 80524

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 50315 potential for actual harm Based on observation, record review and interviews, the facility failed to establish an infection prevention and Residents Affected - Few 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

Findings include:

I. Failure to ensure staff followed EBP when providing care to a resident with a wound

A. Professional reference

According to the Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQs) About Enhanced Barrier Precautions (EBP) In Nursing Homes (6/28/24) retrieved on 1/27/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html,

EBP are an infection control strategy that involves wearing gowns and gloves during high-contact resident care activities. Enhanced Barrier Precautions are recommended for residents with any of the following: infection or colonization, or a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a multi drug resistant organism (MDRO).

B. Facility policy and procedure

The Infection Prevention and Control Program policy and procedure, revised 12/19/16, was received from

the regional director of quality and compliance (RDQC) on 1/22/25 at 4:55 p.m. It documented in pertinent part, The infection prevention and control program bases standards of practice and protocols on recommendations from appropriate government agencies such as the center for disease control (CDC) and

the occupational safety and health administration (OSHA). The facility will utilize practices with employees to reduce the risk that employees will expose residents to infection including taking precautions to reduce the risk for spread of infection from employees to residents by utilizing standard precautions.

C. Observations

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 065166 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065166 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poudre Canyon Rehabilitation and Nursing, LLC 1000 S Lemay Ave Fort Collins, CO 80524

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Registered nurse (RN) #1 was observed on 1/15/25 at 12:30 p.m. while completing wound care for Resident #10. She gathered the supplies and walked into the resident's room. There was a sign on the door that Level of Harm - Minimal harm or indicated the resident was on EBP. There was a caddy hanging on the inside of the door with gowns, masks potential for actual harm and gloves. RN #1 was wearing a mask prior to entering the resident's room. She applied clean gloves. She did not put a gown on. She cleaned the wound and applied medicated ointment to the wound. She removed Residents Affected - Few a stat lock (device to hold catheter in place) because she said it was not in the correct location. She removed

the gloves and washed her hands. She said Resident #10 was on EBP due to his foley catheter. She said

she should have put on a gown and did not think about it when entering the room to complete wound care.

D. Staff interviews

The infection preventionist (IP), the RDQC, the director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 1/22/25 at 3:00 p.m. The IP said Resident #10 was on EBP for his foley catheter. She said any resident that had chronic wounds, a foley catheter, history of (MRSA), ostomies and nasogastric tubes qualified a resident to be on EBP. She said the nurse providing wound care to Resident #10 should have put on a gown while providing care to the resident.

II. Failure to ensure sanitary conditions related to the ice box

A. Professional reference

According to the Centers for Disease Control and Prevention (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities (July 2019) retrieved on 1/27/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc. gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf,

Ice and ice-making machines also may be contaminated via improper storage or handling of ice by patients and/or staff. Suggested steps to avoid this means of contamination include: minimizing or avoiding direct hand contact with ice intended for consumption, using a hard-surface scoop to dispense ice and installing machines that dispense ice directly into portable containers at the touch of a control.

B. Observations

On 1/15/25 at 12:15 an unidentified resident She opened the white and blue ice box that was in the dining room and used her personal cup to scoop the ice directly from the ice box. The resident did not use an ice scoop. An unidentified certified nursing assistant (CNA) was present in the dining room.

C. Staff interviews

The IP, the RDQC, the DON and the ADON were interviewed together on 1/22/25 at 3:00 p.m. The IP said

the residents were not allowed to scoop their own ice from the ice boxes. She said the staff were supposed to help them use a designated scoop to get them ice. She said the staff and the residents should not use their personal cups to scoop ice directly from the ice box.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 065166 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065166 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poudre Canyon Rehabilitation and Nursing, LLC 1000 S Lemay Ave Fort Collins, CO 80524

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37166

Residents Affected - Few Based 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.

Findings include:

A. Observations

On 1/13/25 at 11:35 a.m. the door to the utility room near the dining room between the 300 and 400 units was slightly open. Multiple computer servers and cables were visible in the room.

On 1/14/25 at 10:30 a.m. the door to the utility room near the dining room between the 300 and 400 units was open again and had a medication cart next to the room.

-The door to the room had not been closed by staff when the medication cart had been placed next to the doorway.

On 1/15/25 at 3:40 p.m. the door to the utility room near the dining room between the 300 and 400 units was slightly open again and there was a two-wheel walker folded up and leaning against the wall outside the open door.

-The door to the room had not been closed by staff when the walker had been placed next to the doorway.

On 1/22/25 at 1:50 p.m. the door to room [ROOM NUMBER] was unlocked. Upon opening of the door, the room revealed there were mechanical tools in the room, such as a drill, nails and screws. The dry wall panel was removed from one of the walls and revealed exposed plumbing. The door to the room was not locked and the unsafe contents in the room were accessible to residents on the 500 unit.

B. Staff interviews

The maintenance director (MTD) was interviewed on 1/16/25 at 3:54 p.m. The MTD said the utility room with

the computer equipment had always had the door open since he had worked at the facility. He said he was told it was because the room got too hot and so it needed ventilation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 065166 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065166 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poudre Canyon Rehabilitation and Nursing, LLC 1000 S Lemay Ave Fort Collins, CO 80524

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 The nursing home administrator (NHA) was interviewed on 1/22/25 at 5:20 p.m. The NHA said all utility room doors should be closed and should not be accessible to residents for safety reasons. She said she was not Level of Harm - Minimal harm or aware that room [ROOM NUMBER] had tools in it and was still accessible to residents. She said she would potential for actual harm contact the MTD to ensure the tools were not accessible to residents.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 065166

F-F760: failure to be free from significant medication errors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 40 065166 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065166 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poudre Canyon Rehabilitation and Nursing, LLC 1000 S Lemay Ave Fort Collins, CO 80524

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or 50315 potential for actual harm Based on observations, record review and interviews, the facility failed to ensure that residents were free Residents Affected - Few 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.

Findings include:

I. Manufacturer recommendations

The Novolog medication package insert (February 2023) was retrieved on 2/3/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.novo-pi.com/novolog.pdf. It revealed in pertinent part,

Giving an air shot before injection (after needle application): before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: turn the dose selector to two units, hold your Novolog flex pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. The dose selector should return to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times.

The Humalog medication package insert (July 2023) was retrieved on 2/3/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda. gov/drugsatfda_docs/label/2024/020563Orig1s202,205747Orig1s028Lbl.pdf. It revealed in pertinent part,

Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.

II. Observations

On 1/14/25 at 10:59 a.m., licensed practical nurse (LPN) #1 was observed during medication administration.

She checked Resident #18's blood sugar which was 352 milligrams (mg)/deciliter (dl). She took the Novolog pen out of the medication cart and pulled off the cap, wiped the stopper with an alcohol pad and attached the needle. She prepared 22 units of the Novolog solution for Resident #18. She said eight units were for her scheduled insulin and 14 units were the sliding scale order, which was verified correct per the physician's order. She turned the dose to 22 units and went into the resident's room. She did not prime the insulin pen.

She wiped Resident #18's lower abdomen with an alcohol wipe and injected the medication into her abdomen.

-LPN #1 failed to prime the Novolog insulin pen prior to drawing up the 22 units of insulin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 40 065166 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065166 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poudre Canyon Rehabilitation and Nursing, LLC 1000 S Lemay Ave Fort Collins, CO 80524

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 On 1/14/25 at 11:12 a.m., LPN #1 was observed during medication administration. She checked Resident #46's blood sugar which was 227 mg/dl. She took the Humalog pen out of the medication cart, pulled off the Level of Harm - Minimal harm or cap, wiped the stopper with an alcohol pad and attached the needle. She prepared eight units of Humalog potential for actual harm solution for Resident #46. She said four units were for her scheduled insulin and 4 units were the sliding scale order, which was verified as correct per the physician's order. She turned the dose to eight units and Residents Affected - Few went into the resident's room. She did not prime the insulin pen. She wiped Resident #46's right upper arm with an alcohol wipe and injected the medication into her arm.

-LPN #1 failed to prime the Humalog insulin pen prior to drawing up the eight units of insulin.

Cross reference