Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Poudre Canyon Rehabilitation And Nursing, Llc during CMS and state inspections, most recent first.
A nurse unfamiliar with the unit administered medications intended for another resident to a patient with dementia, epilepsy, and dysphagia, after failing to verify the patient's identity due to missing photo identification in the EMR and absent door nameplate. The patient experienced severe hypotension and required hospitalization. The error was attributed to multiple system failures, including lack of proper resident identification and non-adherence to medication administration protocols.
Multiple residents were not protected from abuse, including repeated alleged sexual abuse by a visitor and physical abuse between residents. In one case, a resident with severe cognitive impairment was subjected to inappropriate touching by a visitor on several occasions, with delayed and insufficient interventions by staff. The facility also failed to promptly investigate and report these incidents, and did not provide immediate staff education to prevent further occurrences. Additionally, two residents were involved in physical altercations without adequate preventive measures in place.
The facility did not submit final reports of abuse investigations to the State Agency within the required five-day period for multiple incidents, including physical and sexual abuse involving several residents and a visitor. Although initial reports were made and investigations completed on time, the final documentation was delayed due to the administrator's failure to submit them promptly.
The facility did not conduct thorough investigations into two abuse allegations, including one involving inappropriate sexual contact with a resident who lacked capacity to consent and another involving a physical altercation between two residents. Key interviews were not completed or documented, and there was a lack of evidence that effective interventions were implemented to ensure resident safety during the investigation process.
A facility failed to protect residents from abuse, with incidents involving inappropriate sexual behavior by a resident with a known history and physical altercations by another resident. Staff were not consistently informed or trained on monitoring requirements, leading to inadequate prevention and response to these incidents.
A facility failed to provide adequate supervision, resulting in a resident sustaining a head injury during a Hoyer lift transfer and another resident leaving the facility unsupervised twice. The first resident, with anoxic brain damage, hit her head on the lift due to erratic movements. The second resident, with dementia, left the facility without timely interventions, despite being at high risk for elopement.
The facility failed to provide palatable and attractive food, as evidenced by resident interviews and a test tray evaluation. Residents reported dissatisfaction with the taste, texture, and appearance of the food, and there was a lack of an alternative menu. A test tray evaluation found issues such as undercooked rice, salty gravy, and overcooked vegetables. The dietary manager did not effectively address these concerns.
The facility's QAPI program failed to address abuse prevention, leading to a repeat deficiency under F600. A resident with a history of sexually inappropriate behavior was not monitored, resulting in immediate jeopardy. Staff interviews revealed a lack of communication and oversight, as the resident's history was not discussed in QAPI meetings.
The facility failed to notify a physician in a timely manner when IV attempts for a resident were unsuccessful, and did not ensure timely review and follow-up of lab results for another resident. This led to deficiencies in care, as one resident's treatment plan was potentially impacted and another's condition deteriorated, requiring emergency room evaluation.
A facility failed to assess and document the use of bed rails for a resident, leading to a deficiency. The resident, with a history of epilepsy and cognitive deficits, had bed rails installed without a safety assessment, care plan, consent, or physician's order. Observations and staff interviews confirmed these oversights.
The facility had a medication administration error rate of eight percent due to an LPN failing to prime insulin pens before administering Novolog and Humalog to two residents. This oversight was observed during medication administration, where the LPN did not follow the manufacturer's instructions to prime the pens, leading to potential dosing inaccuracies. Interviews confirmed that priming is best practice to ensure correct dosing.
Two residents were administered insulin without proper priming of the insulin pens, leading to potential medication errors. An LPN failed to prime both Novolog and Humalog pens before administering doses, contrary to manufacturer recommendations. Interviews confirmed that priming is best practice to ensure correct dosing.
The facility failed to properly store and label medications, as observed in a medication cart on the secure unit. An expired bottle of nitroglycerin spray and an unlabeled container of nitroglycerin tablets were found. Staff interviews revealed that the usual practice of auditing medication carts for expired medications was not effectively implemented, leading to this deficiency.
The facility failed to ensure proper infection control practices, as a nurse did not use appropriate PPE during wound care for a resident on Enhanced Barrier Precautions, and a resident was observed using a personal cup to scoop ice directly from the ice box, contrary to sanitary guidelines.
The facility did not ensure the security of a utility room and a construction area, leaving them accessible to residents. The utility room door was repeatedly found open, exposing computer equipment, while a construction room contained tools and exposed plumbing. Staff interviews revealed a lack of awareness and oversight regarding these safety issues.
Significant Medication Error Due to Resident Misidentification
Penalty
Summary
A significant medication error occurred when a nurse administered medications intended for another resident to an 83-year-old resident with dementia, epilepsy, and dysphagia. The nurse, who was unfamiliar with the unit and the residents, failed to properly identify the resident before administering Lisinopril, Metformin, Seroquel, and Ramelteon—none of which were prescribed for the resident. The nurse did not confirm the resident’s identity using a photo in the electronic medication record (EMR) or a name on the door, as both were missing for this resident. The nurse addressed the resident by another resident’s name, and the resident’s representative did not correct her, leading to the administration of the wrong medications. Following the administration, the resident experienced severe hypotension and tachycardia, requiring transfer to the hospital for intravenous fluids and monitoring. The incident report and subsequent investigation revealed that the nurse realized the error only after returning to the medication cart. The nurse had not worked on the resident’s hall previously and relied on a report sheet that listed the wrong room number. The lack of proper resident identification systems, such as missing photos in the EMR and absent door nameplates, contributed to the error. It was also noted that 17 residents in the facility either did not have a photo in the EMR or a name on their door at the time of the incident. Interviews with staff confirmed that the nurse did not follow the facility’s medication administration policy, which requires verification of the resident’s identity using a photo and adherence to the six rights of medication administration. The nurse had previously made another medication error earlier in the month, which involved administering the wrong dose of a different medication. The facility’s investigation concluded that multiple system failures, including inadequate resident identification and failure to follow established procedures, led to the significant medication error and subsequent hospitalization of the resident.
Failure to Protect Residents from Abuse and Inadequate Investigative Response
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse, including sexual and physical abuse, as well as neglect, as evidenced by several incidents involving both visitors and other residents. In one case, a resident with anoxic brain damage and severe cognitive impairment was subjected to repeated alleged sexual abuse by a visitor, specifically her boyfriend. Despite staff witnessing inappropriate touching on multiple occasions and the resident being unable to consent due to her condition, the facility did not implement timely or effective interventions to prevent further incidents. There were delays in restricting the visitor's access, and staff were not immediately educated on measures to keep the resident safe during ongoing investigations. Additionally, the facility failed to conduct a thorough and timely investigation, including not promptly interviewing the alleged perpetrator and not submitting required reports to the State Agency within the mandated timeframe. In another set of incidents, the facility did not adequately protect two residents from physical abuse by each other. One resident, who had a history of wandering and cognitive impairment, entered another resident's room, leading to a physical altercation. The facility's response and preventive measures prior to the incident were not detailed, but the event highlights a lack of effective supervision and interventions to prevent resident-to-resident altercations, especially among those with known behavioral risks. Additionally, a separate resident was not protected from physical abuse by another resident in two separate incidents. The report details that the facility's policies required immediate investigation and protective measures when abuse was suspected or reported, but these were not consistently followed. The documentation shows that the facility's actions and inactions, including delayed or insufficient interventions, lack of timely staff education, and incomplete investigations, directly contributed to the deficiencies cited by surveyors.
Failure to Timely Submit Final Abuse Investigation Reports
Penalty
Summary
The facility failed to submit final reports of investigations into alleged abuse incidents to the State Survey and Certification Agency within the required five-day timeframe for four out of seven reported abuse allegations. The facility's policy required that all allegations of abuse, neglect, exploitation, or mistreatment be reported immediately to the administrator and appropriate agencies, with final investigation results submitted within five working days. Despite this, the facility delayed the submission of final reports for multiple incidents involving both physical and sexual abuse. Specifically, two separate physical abuse allegations involving two residents were reported initially to the State Agency, but the final reports were submitted 24 days after the deadline. Another physical abuse allegation involving two other residents had its final report submitted 11 days late. Additionally, a sexual abuse allegation involving a resident and a facility visitor was reported initially, but the final investigation report was submitted seven days after the required deadline. Interviews with the nursing home administrator (NHA) and the regional vice-president of operations confirmed that the NHA was aware of the five-day reporting requirement and acknowledged that the investigations themselves were completed on time. However, the NHA admitted to submitting the final reports late due to poor timing skills, resulting in noncompliance with state and federal regulations regarding timely reporting of abuse investigations.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate two separate allegations of abuse, resulting in deficiencies in their response to both a sexual abuse allegation and a physical abuse incident. In the first case, a resident with severely impaired cognition and non-verbal status was allegedly inappropriately touched by her boyfriend, as witnessed by a CNA who heard the resident screaming. The CNA intervened and reported the incident, and the nurse on duty notified the nursing home administrator (NHA) and the police. However, the investigation did not include a direct interview with the witnessing CNA to clarify what was observed, nor was there documentation of an interview with the alleged assailant or evidence that the assailant was restricted from the facility during the investigation. Additionally, there was no documentation of staff education or interventions to ensure the resident's safety while the investigation was ongoing. The resident's capacity to consent to sexual activity was not assessed until after the incident, and despite a determination that the resident could not consent, effective interventions were not implemented to prevent a subsequent incident with the same individual. In the second incident, the facility failed to thoroughly investigate a physical altercation between two residents. The investigation did not specify whether any of the interviewed staff had witnessed or overheard the altercation, and there was no documentation that either resident involved was interviewed to understand the circumstances leading to the incident. The assistant director of nursing (ADON) conducted staff interviews, but these were not specific to the incident, and the NHA did not document attempts to obtain statements from the residents involved. Immediate interventions, such as placing stop signs to prevent further altercations, were mentioned, but the investigation lacked comprehensive documentation and failed to substantiate the abuse based on available statements. Both incidents demonstrate a lack of thoroughness in the facility's investigative process, including incomplete interviews, insufficient documentation, and failure to implement or document effective interventions to ensure resident safety during and after the investigation. The facility's actions did not align with its own policy, which requires immediate and comprehensive investigation of all abuse allegations, including interviews with all involved parties and thorough documentation.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from sexual and physical abuse, specifically involving resident-to-resident interactions. Resident #50, with a known history of sexually inappropriate behaviors, was observed engaging in inappropriate touching of Resident #1. Despite being placed on 15-minute checks, staff interviews revealed a lack of awareness and inconsistent implementation of these checks. This failure to monitor and manage Resident #50's behavior put other residents at risk of sexual abuse. Additionally, Resident #43, who had a history of physical altercations, was involved in multiple incidents of physical abuse against other residents. These incidents included hitting, pushing, and grabbing residents #168, #169, and #25. The facility did not take adequate steps to prevent these altercations or protect the affected residents from harm. The facility's abuse policy, which mandates protection from all forms of abuse and immediate response to incidents, was not effectively implemented. Staff were not consistently informed or trained on the specific behaviors and monitoring requirements for residents with known aggressive or inappropriate behaviors. This lack of communication and training contributed to the facility's failure to prevent and address incidents of abuse, leaving residents vulnerable to harm.
Removal Plan
- Nursing Home Administrator (NHA) has assigned a one-to-one staff member to ensure that Resident #50 is prevented from perpetuating further sexual abuse of resident 1, 18 and other residents.
- The 1:1 staff assignment will continue until the interdisciplinary team is able to coordinate with Behavioral Health Solutions provider, speech therapist and medical director to determine a less restrictive plan of care.
- NHA or designee will inservice the one-to-one staff member regarding the responsibilities of the 1:1 staff member before the start of the shift.
- Director of Nursing (DON) or designee will complete education with all staff before their first shift back to work to ensure they receive updated training and education on Resident #50's care needs and behavioral interventions.
- DON or designee will complete a comprehensive medical record review and interviews with direct care staff to identify any residents with sexually inappropriate behaviors and update the comprehensive care plan and Kardex with effective interventions.
- DON or designee will complete interviews with all residents or resident representatives to identify any residents who have experienced unwanted touching and initiate abuse reporting and update the comprehensive care plan with effective interventions.
- DON or designee will complete education with all staff before their first shift back to work to ensure they receive updated training and education on resident-specific behavior interventions, reporting expectations including reporting any observed physical touching between residents to the abuse coordinator, accessing care plans and Kardexes and expectations for review of care plans and Kardexes at the start of each shift for any changes.
Inadequate Supervision Leads to Resident Injury and Elopement
Penalty
Summary
The facility failed to provide adequate supervision and prevent accidents for two residents, leading to significant incidents. One resident, who required a Hoyer lift and two-person assistance for transfers due to anoxic brain damage and erratic body movements, sustained a head laceration during a transfer. The incident occurred when the resident hit her head on the Hoyer lift bar, resulting in a laceration that required emergency department treatment and seven sutures. The facility's failure to monitor the resident's erratic movements closely during the transfer contributed to this injury. Another resident, diagnosed with senile degeneration of the brain and dementia, left the facility unsupervised on two occasions. Despite being identified as a high risk for wandering and elopement, the facility did not implement timely safety interventions. The resident first left the facility unsupervised to go to a gas station, and a second incident occurred without any interventions being put in place after the first elopement. The facility failed to conduct a Wander/Elopement Risk evaluation following the second incident, and a wander guard was not placed on the resident until several months later. The facility's policies and procedures for safety precautions and elopement prevention were not adequately followed, leading to these deficiencies. The lack of timely and appropriate interventions for both residents highlights the facility's failure to ensure a safe environment and adequate supervision to prevent accidents and elopements.
Facility Fails to Provide Palatable and Attractive Food
Penalty
Summary
The facility failed to provide food that was palatable and attractive, as evidenced by multiple resident interviews and a test tray evaluation. Several residents expressed dissatisfaction with the taste, texture, and appearance of the food. They reported that the food was not good, with some residents noting that the quality depended on who was cooking. Additionally, there was a lack of an alternative menu, and the kitchen often closed before residents could request different options if they were dissatisfied with their meals. The resident group interview further confirmed these issues, with comments about the food being questionable, not looking good, and being too spicy. The dietary manager was noted to not address or resolve these concerns effectively. The review of food committee meeting minutes from October 2024 to January 2025 showed that residents had previously expressed concerns about the food, such as wanting more fruit and less salty food, but there was no documentation of actions taken to address these issues. During a test tray evaluation, surveyors found the food to be unpalatable, with undercooked rice pilaf, salty gravy, hard meatballs, and overcooked brussel sprouts. The dietary manager, when interviewed, claimed that residents were satisfied with the food choices and did not acknowledge the issues with the rice pilaf.
Failure to Address Abuse Prevention in QAPI Program
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program to identify and address compliance concerns, specifically related to abuse prevention. During a recertification survey, the facility was cited for failing to maintain compliance with abuse prevention standards, as evidenced by a repeat deficiency under F600. Initially cited at a G level for isolated actual harm, the deficiency escalated to a K level, indicating a pattern of immediate jeopardy to residents' health and safety. This was due to the facility's failure to monitor a resident with a known history of sexually inappropriate behavior, which was not addressed in QAPI meetings. Interviews with facility staff revealed gaps in communication and awareness regarding the resident's history of inappropriate behavior. The Nursing Home Administrator (NHA) acknowledged that the resident's history was documented but not acted upon until an incident occurred. The Medical Director was unaware of the resident's history until after the incident, indicating a lack of communication and oversight. Despite monthly QAPI meetings, the issue of sexually inappropriate behaviors was not identified as a problem, contributing to the deficiency.
Failure to Ensure Timely Physician Notification and Lab Result Follow-Up
Penalty
Summary
The facility failed to ensure timely notification of a physician when attempts to start an intravenous (IV) line for a resident were unsuccessful. Resident #167, who had severe cognitive impairment and required extensive assistance, experienced a change in condition with symptoms such as falls, shortness of breath, and decreased urine output. Despite a physician's order for immediate IV fluids, the nursing staff was unable to start the IV and did not notify the primary care physician (PCP) until the following day. This delay in communication potentially impacted the resident's treatment plan. Additionally, the facility did not ensure timely review and follow-up of laboratory results for Resident #64, who had a history of type 2 diabetes, stroke, and hypertension. The resident's physician ordered lab work due to changes in the resident's behavior, such as skipping meals and smoke breaks. Although the lab work was completed and submitted to the facility, there was no documentation indicating that the physician reviewed the results or provided feedback. The facility also failed to follow up with the physician when feedback was not received, and the resident's condition deteriorated, leading to an emergency room visit. Interviews with staff, including the Director of Nursing (DON) and the Nursing Home Administrator (NHA), revealed a lack of adherence to the facility's policy for notifying physicians of changes in a resident's condition. The DON stated that orders from physicians should be completed immediately unless there is another emergency, and if a nurse is unable to carry out an order, the physician should be notified right away. However, in both cases, there was a failure to communicate effectively with the physicians, resulting in deficiencies in the quality of care provided to the residents.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to use a person-centered approach in determining the use of bed rails for a resident, leading to a deficiency. The facility did not assess the resident for the safe use of bed rails, including the risk of entrapment, before installing them. Additionally, the facility did not create or document a personal care plan for the safe use of bed rails, nor did they obtain consent from the resident or the resident's representative after discussing the risks and benefits. Furthermore, the facility did not obtain a physician's order for the bed rails or conduct quarterly assessments to evaluate their continued need and safety. The resident involved was a 65-year-old with a history of generalized idiopathic epilepsy, cognitive communication deficit, traumatic brain injury, sleep apnea, depression, and GERD. Despite being cognitively intact and requiring assistance with activities of daily living, the resident's comprehensive care plan and electronic medical record lacked documentation regarding the use of bed rails. Observations revealed that bed rails were installed without proper assessment or consent, and staff interviews confirmed that the necessary assessments were not completed prior to installation.
Medication Administration Errors Due to Failure to Prime Insulin Pens
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, with an observed error rate of eight percent. This deficiency was identified during a survey where two errors were noted out of 25 opportunities for error. The errors involved the administration of insulin using Novolog and Humalog pens without priming them as per the manufacturer's instructions. Priming is essential to remove air from the needle and cartridge, ensuring the correct dose is administered. The failure to prime the insulin pens was observed during medication administration for two residents. In the first instance, an LPN administered 22 units of Novolog insulin to a resident with a blood sugar level of 352 mg/dl without priming the pen. Similarly, in the second instance, the same LPN administered eight units of Humalog insulin to another resident with a blood sugar level of 227 mg/dl, again without priming the pen. Interviews with the nurse practitioner and the director of nursing confirmed that priming the insulin pen is considered best practice to ensure the resident receives the full dose of insulin. The failure to prime the insulin pens led to the medication administration errors noted in the report.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. Two residents, identified as Resident #18 and Resident #46, were administered insulin without the proper priming of the insulin pen, as observed during medication administration. The Novolog and Humalog insulin pens were not primed before administering the doses, which is against the manufacturer's recommendations. This failure to prime the insulin pens could result in the residents receiving incorrect doses of insulin. During the observations, LPN #1 was responsible for administering the insulin to both residents. For Resident #18, the LPN prepared 22 units of Novolog insulin without priming the pen, and for Resident #46, eight units of Humalog insulin were prepared and administered without priming. Interviews with the nurse practitioner and the director of nursing confirmed that priming the insulin pen is considered best practice to ensure the correct dose is administered. The facility's failure to follow these procedures led to the deficiency noted in the report.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and labeled according to professional standards. During an observation of the medication cart and treatment cart on the secure unit, it was found that there was a bottle of nitroglycerin lingual spray with an expiration date of June 2023 and a container of nitroglycerin sublingual tablets that lacked a label indicating which resident it belonged to. This indicates a failure to remove expired medications and to ensure all medications are labeled with resident information. Interviews with staff revealed that the usual practice was for the night shift nurse to audit the medication carts for expired medications. However, this process was not effectively implemented, as evidenced by the presence of expired and unlabeled medications. The Director of Nursing (DON) stated that medication carts and storage rooms were reviewed weekly, but the expired medication should have been removed and destroyed by the nurse who found it. The facility's policy requires that medications be labeled with resident information and that expired medications be returned or destroyed, which was not adhered to in this instance.
Infection Control Deficiencies in PPE Use and Ice Box Sanitation
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by two specific deficiencies. Firstly, a registered nurse did not adhere to Enhanced Barrier Precautions (EBP) while providing wound care to a resident with a Foley catheter. Despite a sign indicating the need for EBP and the availability of personal protective equipment (PPE) such as gowns, masks, and gloves, the nurse only wore a mask and gloves, neglecting to don a gown. This oversight occurred during wound care, which involved cleaning the wound and applying medicated ointment. The nurse acknowledged the lapse, attributing it to a lack of attention to the precautionary requirements. Secondly, the facility failed to maintain sanitary conditions concerning the ice box in the dining room. An unidentified resident was observed using a personal cup to scoop ice directly from the ice box, bypassing the use of a designated ice scoop. This action was witnessed by a certified nursing assistant who did not intervene. The infection preventionist confirmed that residents were not permitted to scoop their own ice and that staff were responsible for assisting residents using a designated scoop to prevent contamination.
Facility Fails to Secure Utility and Construction Areas
Penalty
Summary
The facility failed to maintain a safe and secure environment for residents by not ensuring that certain areas were inaccessible to them. Observations revealed that the utility room door near the dining room between the 300 and 400 units was repeatedly found open on multiple occasions, exposing computer servers and cables. Staff did not close the door when placing items such as a medication cart and a two-wheel walker near the doorway, leaving the room accessible to residents. Additionally, room [ROOM NUMBER] on the 500 unit, which was under construction, was found unlocked and accessible to residents. The room contained mechanical tools, such as a drill, nails, and screws, and had exposed plumbing due to a removed drywall panel. Interviews with the maintenance director and the nursing home administrator confirmed that the utility room door was left open for ventilation purposes, and the administrator was unaware of the construction room's accessibility and contents.
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Illustrative
What surveyors actually found near you
We read the 127 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Collins
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Storybrook Care & Rehabilitation | 0 mi | ★★★★★ | 4 | 0 |
| Rehabilitation And Nursing Center Of The Rockies | 0.5 mi | ★★★★★ | 2 | 0 |
| Creekside Village Rehabilitation And Nursing Llc | 0.7 mi | ★★★★★ | 36 | 3 |
| Columbine West Health And Rehab Llc | 2 mi | ★★★★★ | 0 | 0 |
| Centre Avenue Health And Rehab Llc | 2 mi | ★★★★★ | 1 | 0 |
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