Deficiency Records for Poudre Canyon Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Poudre Canyon Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-07-13 | 2023-09-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-02 | 2023-09-08 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-07-13 | 2023-07-14 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-07-13 | 2023-07-14 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-07-13 | 2023-07-14 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-07-13 | 2023-07-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-13 | 2023-07-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-13 | 2023-07-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-13 | 2023-07-13 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-07 | 2022-09-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-07 | 2022-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-07 | 2022-08-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-07 | 2022-08-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-07 | 2022-08-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-07 | 2022-08-29 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-07-07 | 2022-08-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-16 | 2022-07-16 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-06-16 | 2022-07-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-06-16 | 2022-07-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-16 | 2022-07-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-16 | 2022-07-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-06-16 | 2022-07-16 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-06-16 | 2022-07-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-16 | 2022-07-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-16 | 2022-07-16 | N |
| Provide or obtain dental services for each resident. | Health | 2022-06-16 | 2022-07-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-16 | 2022-07-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-16 | 2022-07-16 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-16 | 2022-07-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-16 | 2022-07-16 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-07 | 2022-07-11 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-05-25 | 2021-06-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-25 | 2021-06-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-25 | 2021-06-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-25 | 2021-06-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-25 | 2021-06-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-05 | 2021-06-04 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-05-05 | 2021-06-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-05 | 2021-06-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-05 | 2021-06-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-05 | 2021-06-04 | N |
