Poudre Canyon Rehabilitation and Nursing, LLC

In the surveyor’s words

From the most serious findings on record at Poudre Canyon Rehabilitation and Nursing, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jan 22, 2025

  Based on interviews and record review, the facility failed to protect and promote an environment free from resident-to-resident sexual and physical abuse. The facility failure affected five of five residents reviewed for abuse (#1, #18, #168, #25 and #169) out of 38 sample residents. The facility's failure contributed to incidents of abuse by Residents #50 and #43 and created the potential the abuse would recur. Resident #50 had a history of sexually inappropriate behaviors. On 1/1/25, he was observed rubbing Resident #1's back and putting his hand down the front of her shirt. Resident #1 reported to the facility that he had done the same to other residents. […]

• Actual harm, isolatedF689Jul 28, 2026

  Based on observations, record review and interviews, the facility failed to ensure one (#6) of one resident reviewed for accidents and hazards received adequate supervision to prevent an elopement out of 26 sample residents. Resident #6 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance, chronic respiratory failure and traumatic brain injury. Beginning in January 2026, the resident began displaying elopement seeking behavior and was telling staff he wanted to leave the facility. His exit-seeking behaviors escalated, which prompted a review from the physician, who recommended a wanderguard device and expressed serious concerns regarding his safety, poor insight, and impaired judgement. […]

• Actual harm, isolatedF760May 15, 2025

  Based on record review and interviews, the facility failed to ensure one (#10) of five residents reviewed for medication management were free from significant medication errors out of 22 sample residents. Resident #10 was admitted to the facility on [DATE] with a diagnosis of dementia. On 4/29/25 a nurse administered Resident #10 Lisinopril (used to treat high blood pressure), Metformin (used to treat diabetes), Seroquel (used to treat mental health conditions) and Ramelteon (used to treat insomnia). The resident began to experience severe hypotension (a dangerously low blood pressure) and was sent to the hospital. The resident received intravenous fluids and was monitored. […]

• Actual harm, isolatedF689Jan 22, 2025

  Based on observations, record review and interviews, the facility failed to provide adequate supervision to keep residents free from accidents/hazards for two (#23 and #28) of five residents reviewed for accidents out of 38 sample residents. Resident #23, who was admitted on [DATE], required the use of a Hoyer lift (mechanical lift) and two-person staff assistance for transfers. Interviews during the survey revealed the resident had erratic body movements due to her diagnosis of anoxic brain damage (a condition caused by the brain being deprived of oxygen and leading to brain cell death). On 1/12/25, Resident #23 was being transferred by two staff members and hit her head on the bar of the Hoyer lift. […]

• Actual harm, isolatedF600Jul 13, 2023

  Based on record review and interviews, the facility failed to take steps to protect the right to be free from abuse and neglect for one resident (#18) of five out of 36 sample residents. The facility failed to keep Resident #18 free from abuse when certified nurse aide (CNA) #4 who delivered medication to Resident #18, held her hand over the resident's mouth in an attempt to force the resident to swallow sedating medication for ongoing behaviors. Through the course of the investigation, the facility failed to prevent another abuse incident for Resident #18 when CNA #4 pulled the resident's wheelchair in a manner that resulted in a fearful response by the resident. […]