Poudre Canyon Rehabilitation And Nursing, Llc
POUDRE CANYON REHABILITATION AND NURSING, LLC in FORT COLLINS, CO — inspection on May 15, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
According to the May 2025 computerized physician orders (CPO), diagnoses included dementia, epilepsy (seizure disorder) and dysphagia (difficulty swallowing).
The 2/17/25 minimum data set (MDS) assessment indicated the resident had short term and long term memory problems and her cognitive skills for daily decision making were moderately impaired, per staff assessment. Resident #10 was dependent on staff for personal hygiene, toileting and transferring.
C.
Record review
The 4/29/25 incident report was documented at 7:00 p.m. by registered nurse (RN) #3.
The incident reported documented RN #3 obtained the wrong medications for Resident #10. RN #3 documented Resident #10 did not have a picture in the electronic medication record (EMR) and her name was not on the door. RN #3 documented she had not worked on the resident's hall previously and was not familiar with the residents. RN #3 documented upon entering Resident #10's room, the resident's representative was at the bedside. RN #3 addressed Resident #10 by another resident's first name (to whom she thought was administering the medications) and the family responded without correction. RN #3 documented the following medications were administered to Resident #10 that were not ordered for her: Lisinopril 20 milligrams (mg), Metformin 500 mg, Seroquel 100 mg and ramelteon 8 mg.
The April 2025 CPO revealed Resident #10 had physician's orders for the following daily scheduled medications: mirtazapine (used to treat depression) 45 mg, olanzapine (used to treat mental health conditions)10 mg, tramadol (used to treat pain) 50 mg and divalproex sodium (used to control seizures) 125 mg.
-Resident #10 did not have physician's orders for Lisinopril, Metformin, Seroquel or ramelteon.
065166
Form Approved OMB
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 05/15/2025
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
According to the staff assessment for mental status, the resident had short and long-term memory problems and her cognitive skills for daily decision making were severely impaired.
2.
Record review
The communication care plan, revised 12/20/24, revealed Resident #9 had impaired cognition and communication deficits related to anoxic brain injuries.
Interventions included staff to ensure visits with the boyfriend happened in community areas and the boyfriend was not permitted to be in a room with the resident without staff or the resident's parents present.
-However, the intervention was not initiated until 4/18/25, six days after the alleged incident on 4/12/25.
The psychosocial well-being care plan, initiated 4/12/25 and revised 5/7/25, revealed Resident #9 had a potential for alteration to psychosocial well-being related to being a victim of alleged sexual abuse.
Interventions included monitoring and documenting the resident's verbal reactions to situations that may indicate her feelings, initiated 4/12/25.
Additional interventions , initiated on 5/7/25 (during the survey), included encouraging Resident #9 to participate in meaningful relationships.
The resident was in a romantic relationship prior to her accident and her family felt it was beneficial for her to maintain her relationship. If her boyfriend visited, they should meet in a common area or in the presence of the resident's parents.
The 5/7/25 interventions additionally included monitoring the resident's mood and behavior, providing opportunities for the resident and family to participate in care and the resident was assessed as not having the capacity to consent to sexual activity.
The trauma informed care plan, revised 11/1/24, revealed Resident #9 had a history of trauma that affected her negatively.
Interventions included that the resident's boyfriend was not allowed visitation. If he showed up at the facility, staff was to notify the police (initiated 5/7/25 and revised 5/13/25).
A sexual activity capacity for consent was completed on 4/14/25. It revealed Resident #9 had a history of anoxic brain injury, she was unable to communicate effectively, and she was unable to determine the level of cognitive status.
Due to the resident's inability to communicate effectively and describe her thoughts and feelings, the IDT determined the resident could not make or express her desire to engage in sexual intimacy with others.
-However, despite the determination that Resident #9 did not have the capacity to consent to sexual intimacy, the facility failed to put effective interventions in place to protect the resident from another alleged sexual incident with the boyfriend on 4/23/25 (see investigation above).
065166
Form Approved OMB
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 05/15/2025
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
F-F610 for failure to fully investigate an allegation of sexual abuse.
-Additionally, the facility failed to submit a final report of the investigation to the State Agency until 4/24/25, seven days after the final report was due.
Cross-reference