POUDRE CANYON REHABILITATION AND NURSING, LLC
Open-data reference.
POUDRE CANYON REHABILITATION AND NURSING, LLC is a for profit - limited liability company facility in FORT COLLINS, CO with 83 certified beds and a 2-star overall CMS rating. The facility has 37 deficiency records on file. Total penalties: $46K.
1000 S LEMAY AVE, FORT COLLINS, CO 80524
Phone: 9704827925
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 065166
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 83
- Residents
- 73
- In Hospital
- No
- County
- Larimer
- Last Inspection
- Jan 22, 2025
Staffing Data
- RN Hours
- 0.56 (nat'l avg: 0.68)
- LPN Hours
- 0.57
- CNA Hours
- 1.59
- Total Nursing Hours
- 2.72 (nat'l avg: 3.89)
- PT Hours
- 0.02
- Nursing Turnover
- 77.5%
- RN Turnover
- 75.0%
What the CMS Record Reveals About POUDRE CANYON REHABILITATION AND NURSING, LLC
POUDRE CANYON REHABILITATION AND NURSING, LLC operates 83 certified beds in FORT COLLINS, CO with approximately 73 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (1★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 37 deficiency records from recent surveys, of which 6 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $46K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 2.72 total nursing hours per resident day (national average 3.89), with RN coverage at 0.56 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, POUDRE CANYON REHABILITATION AND NURSING, LLC falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 77.5%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (37 most recent)
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: May 16, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 16, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 16, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 16, 2025
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 23, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 6, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 19, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Feb 19, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Feb 19, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Feb 6, 2025
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Feb 14, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 15, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 6, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Feb 19, 2025
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Feb 19, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 5, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 14, 2023
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Jul 14, 2023
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Category: Nutrition and Dietary Deficiencies
Corrected: Sep 29, 2023
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 14, 2023
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 14, 2023
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category: Resident Rights Deficiencies
Corrected: Jul 14, 2023
The resident has the right to receive notices in a format and a language he or she understands.
Category: Resident Rights Deficiencies
Corrected: Jul 14, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jul 16, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 16, 2022
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 16, 2022
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 16, 2022
Provide or obtain dental services for each resident.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 16, 2022
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 16, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 16, 2022
Assist a resident in gaining access to vision and hearing services.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 16, 2022
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 16, 2022
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 16, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 16, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Jul 16, 2022
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category: Resident Rights Deficiencies
Corrected: Jul 16, 2022
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Jul 16, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 16.3% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 6.1% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.7% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 4.6% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.8% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 93.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 72.9% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 16.8% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 15.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 87.5% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 63.2% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.8% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 18.8% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 26.2% | Yes |
Penalty History 2 penalties totaling $46K
| Date | Type | Amount |
|---|---|---|
| Jan 22, 2025 | Fine | $38K |
| Aug 2, 2023 | Payment Denial | - |
| Jul 13, 2023 | Fine | $8K |
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Frequently Asked Questions
What is the overall CMS rating for POUDRE CANYON REHABILITATION AND NURSING, LLC?
What are the staffing levels at POUDRE CANYON REHABILITATION AND NURSING, LLC?
How many beds does POUDRE CANYON REHABILITATION AND NURSING, LLC have?
Does POUDRE CANYON REHABILITATION AND NURSING, LLC have any deficiencies on record?
Has POUDRE CANYON REHABILITATION AND NURSING, LLC received any fines or penalties?
Who owns POUDRE CANYON REHABILITATION AND NURSING, LLC?
When was POUDRE CANYON REHABILITATION AND NURSING, LLC last inspected?
What quality measures are tracked for POUDRE CANYON REHABILITATION AND NURSING, LLC?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.