Poudre Canyon Rehabilitation and Nursing LLC

A survey prompted by complaint #CO40177 was completed on 5/6/25 to 5/15/25. One deficiency was cited. 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 2/10/25 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. Specifically, the facility failed to ensure Resident #10 did not receive another resident' s (Resident #20) medications.Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G et.al,, Fundamentals of Nursing, 10th ed., Elsevier, St. Louis, Missouri, pp. 606-607, "Take appropriate actions to ensure the patient receives medication as prescribed. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications:1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication."II. Facility policy and procedureThe Medication Administration policy, revised 4/11/25, was provided by the nursing home administrator (NHA) on 5/7/25 at 10:38 a.m. It read in pertinent part, "Identify resident by photo in the MAR (medication administration record)."Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time and right documentation."The Medication Error policy, revised 2025, was provided by the NHA on 5/7/25 at 10:38 a.m. It read in pertinent part, "The facility shall ensure medications will be administered as follows: according to physician' s orders, per manufacturer' s specifications and in accordance with accepted standards..

A complaint survey, prompted by #CO39626, #CO39822, #CO39974, Incident #39820, Incident #39821, Incident #39910 and Incident #39940 was conducted on 5/6/25 to 5/15/25. Four deficiencies were cited. 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 2/10/25 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. Specifically, the facility failed to ensure Resident #10 did not receive another resident' s (Resident #20) m.. Based on record review and interviews, the facility failed to report alleged violations of sexual and physical abuse to the State Survey and Certification Agency in accordance with state law for four of seven alleged abuse violations.Specifically, the facility failed to:-Submit a final report of the facility' s investigation of two separate physical abuse allegations involving Resident #5 and Resident #4 to the State Agency within five calendar days of the incidents;-Submit a final report of the facility' s investigation of a physical abuse allegation involving Resident #7 and Resident #8 to the State Agency within five calendar days of the incident; and,-Submit a final report of the facility' s investigation of a sexual abuse allegation involving Resident #9 and a facility visitor to the State Agency within five c.. Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for two of seven abuse allegations. Specifically, the facility failed to: -Thoroughly investigate an allegation of sexual abuse on 4/12/25 for Resident #9 in order to prevent a second incident from occurring on 4/23/25; and, -Thoroughly investigate an allegation of physical abuse between Resident #7 and Resident #8. I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, revised 4/11/25, was provided by the director of nursing (DON) on 5/6/26 at 12:22 p.m. It read in pertinent part, "An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.""Written procedures for investigations include investi.. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.