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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Canyons Post-acute during CMS and state inspections, most recent first.
A resident with hemiplegia, encephalopathy, dysphagia, and documented dependence for oral hygiene, as well as dental findings of generalized bone loss and periodontitis, did not receive adequate staff-assisted oral care. The resident’s daughter alerted an LVN to an abnormal finding in the resident’s mouth, which the LVN observed as multiple small white moving spots resembling larvae and described as a moderate amount. A nurse was called to assess the resident, and the larvae were removed using peridex and a yankauer. The ADON later acknowledged that the facility’s ADL policy requiring staff to maintain oral hygiene for residents unable to do so independently had not been followed.
A resident with chronic respiratory failure and documented CRAB/KPC infection was on contact precautions with physician orders and facility policy requiring staff to wear gown and gloves before entering the room and to follow hand hygiene and glove-use protocols. Despite isolation signage on the door, a CNA entered the room and picked up the resident’s call light from the floor without wearing gloves, later stating she had forgotten, while the ADON and DSD confirmed this was unacceptable and contrary to the facility’s isolation procedures.
Surveyors found that staff failed to keep call lights within reach for two residents, one with chronic respiratory failure and another with hemiplegia, hemiparesis, and a tracheostomy. In one case, a CNA located the resident’s call light on the floor while the resident was in bed; in the other, the ADON found the call light wrapped around a bed rail, out of the resident’s reach. These situations did not comply with the facility’s policy requiring call lights to be within easy reach when residents are in bed or confined to a chair, creating the potential for delayed assistance, unmet care needs, and possible injury.
A resident with anxiety disorder, hematuria, and psychosis was transferred to a GACH after intentionally removing a catheter, causing profuse bleeding. Nursing staff documented the transfer and MD notification, and an LVN reported calling the resident’s daughter only to inform her of the hospital transfer. Facility records claimed the daughter was notified of a 7‑day bed‑hold option and declined it, but the form lacked the time of the call and the staff member’s name. The RN Supervisor denied making any bed‑hold notification call, and the daughter reported receiving no verbal or written information about bed‑hold rights. Review of the facility’s Bed‑Holds and Returns policy with the DON and ADON confirmed that required written information about bed‑hold rights at or shortly after transfer was not provided, and the DON acknowledged the policy was not followed.
Two residents with significant medical histories, including repeated falls and a recent fracture, were found unable to access their call lights due to improper placement and obstruction by furniture. Staff interviews and policy review confirmed that call lights were not within reach as required, and facility leadership acknowledged the deficiency.
The facility did not ensure continuous RT coverage for several hours during a night shift, leaving residents without access to a respiratory therapist. A resident reported that nurses were unable to operate respiratory equipment, resulting in the resident remaining off the machine. Staff interviews and timesheet reviews confirmed the absence of RT staff, and the DON acknowledged the facility did not follow its staffing policy.
A resident with end stage renal disease missed two scheduled dialysis treatments after readmission due to the facility's failure to obtain necessary consent and complete required paperwork, resulting in the resident being sent to an acute hospital for treatment. Staff interviews revealed confusion about the process for re-establishing dialysis services and a lack of timely follow-up on required documentation.
A CNA did not perform hand hygiene after removing PPE when leaving the isolation rooms of two residents on contact precautions for MDROs. The CNA stated she did not clean her hands because she believed she had not touched anything, despite facility policy and CDC guidelines requiring hand hygiene after glove removal. The DON confirmed that hand hygiene should have been performed.
Two residents who were clinically compromised and dependent on ventilators were found to be using equipment that was overdue for scheduled preventative maintenance. Staff interviews confirmed that the facility's policy for routine equipment maintenance was not followed, and the process for notifying and arranging service was not effectively implemented.
Three residents with complex medical conditions were found soiled and wet, with their briefs and linens saturated, due to lapses in timely incontinence care. Staff interviews confirmed that residents were not changed as required by the facility's ADL policy, and the DON acknowledged that residents should not have been left in this condition.
A resident's admission MDS assessment was not completed within the required 13-day timeframe after admission, as it was finalized on March 6, 2025, instead of within the allowed period. The MDS Coordinator admitted the delay was due to being busy, and the facility lacked a specific policy for MDS assessments, relying on the RAI Manual instead.
A resident's discharge MDS was inaccurately coded, indicating discharge to a hospital instead of home with hospice services. Facility staff, including the MDS Coordinator and DON, confirmed the error, acknowledging the resident was discharged home with hospice as per family request.
A facility failed to monitor a resident for adverse drug reactions or side effects related to the use of Zyprexa, an antipsychotic medication. Despite facility policy requiring monitoring, the resident's order summary lacked such orders. Interviews with LVNs and the DON confirmed the absence of monitoring orders, which should have been initiated when the medication was prescribed.
A facility failed to disinfect a clipboard between uses for two residents requiring contact precautions due to carbapenem-resistant infections. An LVN moved the clipboard between the residents' beds without cleaning it, contrary to the facility's policy. Interviews with staff confirmed the oversight and the importance of using Clorox wipes for disinfection to prevent cross-contamination.
Three residents experienced prolonged wait times for assistance due to staffing shortages and non-compliance with ADL policies. A resident with chronic respiratory failure waited over an hour for help, while another with necrotizing fasciitis faced similar delays. A third resident with a stage 4 pressure ulcer also experienced care delays. CNAs reported systemic staffing issues, with management aware but not effectively addressing them. The DON acknowledged expectations for prompt response to call lights, but these were not consistently met, risking residents' health.
Two residents reported issues with the shower room, including uneven flooring, fractured tiles, and permanent residue on the walls. The room was described as dirty, with gloves on the floor and inconsistent hot water availability. The Director of Maintenance and Housekeeping confirmed these issues, and the Director of Nursing acknowledged the room's unclean appearance. The facility's maintenance policy was not followed, impacting residents with osteomyelitis, type 2 diabetes, chronic respiratory failure, a tracheostomy, and epilepsy.
A resident in a persistent vegetative state was left unattended during care, leading to a fall and injury. The CNA left to gather supplies, and upon returning, found the resident on the floor with a cut and dislodged G-tube. The resident was transferred to a hospital for evaluation. Known tendencies of the resident to lean forward when coughing were not addressed with appropriate fall precautions.
The facility failed to respond to call lights in a timely manner, affecting three residents with significant medical conditions. One resident reported waiting over 20 minutes for assistance at night, another typically waited an hour, and a third experienced a six-hour delay, leading to discomfort from an unchanged diaper. Staff acknowledged the delays, citing understaffing as a reason, despite a policy requiring responses within 10 to 15 minutes.
A resident with multiple health issues refused wound care for three days, but the facility failed to document these refusals properly or notify the physician. The treatment nurse only observed the wounds without performing necessary treatments, and the TAR was inaccurately marked as completed. This lack of documentation and communication led to the resident's condition worsening, resulting in an infection and hospital stay.
A resident with complex medical needs was admitted to a facility without a comprehensive nursing assessment, leading to a critical error where enteral feeding was connected to a paracentesis drainage tube instead of a gastrostomy tube. This resulted in severe abdominal pain and subsequent death after being transferred to a hospital.
A resident with complex medical needs experienced a fatal incident due to a nurse's error in a LTC facility. The nurse mistakenly infused enteral feeding into a paracentesis drainage tube instead of the gastrostomy tube, leading to severe abdominal pain and hospitalization. Interviews revealed that staff lacked specific training on managing paracentesis drainage tubes, contributing to the error.
Two residents in the facility experienced significant delays in staff responses to call lights, contrary to the facility's policy. One resident, with a self-care deficit due to deconditioning, reported delays of up to two hours, particularly during night shifts, and infrequent repositioning. Another resident, with chronic kidney disease and other health issues, faced delays of 30 minutes or more, affecting their ability to receive timely assistance with daily activities. Both residents' care plans emphasized the need for prompt response to call lights, which was not consistently followed.
A resident developed a stage 4 pressure ulcer due to the facility's failure to follow its policy of repositioning dependent residents every two hours. The resident, who required maximum assistance for bed mobility, reported delayed staff responses and inadequate repositioning, leading to the ulcer's development.
Failure to Provide Adequate Oral Hygiene Resulting in Larvae in a Resident’s Mouth
Penalty
Summary
The facility failed to provide proper oral care for a dependent resident who required staff assistance with oral hygiene. The resident was admitted with diagnoses including hemiplegia and hemiparesis affecting the left non-dominant side following a stroke, encephalopathy, and dysphagia, and an MDS assessment indicated the resident was dependent for oral hygiene, meaning staff were responsible for performing all aspects of this care. A treatment sheet documented that a comprehensive dental evaluation had identified generalized bone loss and periodontitis. Despite these needs and findings, the resident’s oral hygiene was not adequately maintained. Nursing documentation showed that a registered nurse was called to the resident’s room by the charge nurse after larvae were found inside the resident’s mouth. In a subsequent telephone interview, an LVN reported that the resident’s daughter had alerted her to something inside the resident’s mouth, which the LVN observed as small white moving spots resembling white larvae, present in a moderate amount. The LVN stated these were removed using peridex and a yankauer suction device. During an interview and record review, the ADON acknowledged that the facility’s ADL policy, which requires that residents unable to perform activities of daily living independently receive services to maintain personal and oral hygiene, was not followed in this case.
Failure to Follow Contact Precaution PPE Requirements
Penalty
Summary
The facility failed to maintain infection control practices for a resident on contact-precaution isolation when a CNA did not follow required personal protective equipment (PPE) protocols. The resident had chronic respiratory failure and a documented infection with Klebsiella pneumoniae, and a physician’s order dated June 1, 2023, directed contact precautions every shift for CRAB and KPC infection, including wearing a gown and gloves before entering the room or caring for the resident. Facility policy titled “Isolation - Categories of Transmission-Based Precautions,” dated October 2018, required staff and visitors to wear clean, non-sterile gloves when entering the room, to change gloves after contact with infective material, to remove gloves and perform hand hygiene before leaving the room, and to avoid touching potentially contaminated environmental surfaces or items after gloves were removed. On the survey date, signage on the resident’s door indicated the resident was on contact precautions. During observation at 10:45 AM, the CNA was seen in the resident’s room picking up the resident’s call light from the floor without wearing gloves. In a concurrent interview, the CNA acknowledged she had forgotten to wear gloves and stated she understood the importance of wearing gloves to protect herself and the resident. In separate interviews, the ADON and the DSD each stated it was unacceptable for the CNA to be in the contact isolation room without gloves and confirmed that all staff were required to follow the established isolation protocols, including glove use in contact isolation rooms.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure resident call lights were within reach as required by facility policy. For one resident with chronic respiratory failure and Klebsiella pneumoniae, an observation and interview with a CNA in the resident’s room found the resident lying in bed while the call light was located on the floor, out of the resident’s reach. The CNA searched for the call light, located it on the floor, and stated that the call light should be within the resident’s reach. In a separate observation and interview with the ADON involving another resident with hemiplegia and hemiparesis affecting the right dominant side and tracheostomy status, the resident was also lying in bed when the ADON searched for the call light and found it wrapped around the bed rail, not within the resident’s reach. The ADON stated that staff must have neglected to place the call light within reach after attending to the resident and described this as unacceptable. Review of the facility’s undated “Answering the Call Light” policy indicated that when a resident is in bed or confined to a chair, the call light is to be within easy reach of the resident. These observations showed that staff did not follow the facility’s policy for two of four sampled residents, which the report states had the potential to delay their ability to request assistance when needed, increasing the risk of unmet care needs and possible injury.
Failure to Notify Resident Representative of Bed-Hold Rights at Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its Bed-Holds and Returns policy for a resident who was transferred to a general acute care hospital. The resident, who had diagnoses including anxiety disorder, hematuria, and psychosis, was initially admitted on an unspecified date and had his daughter listed as his responsible party. On January 4, 2026, nursing notes documented that at approximately 4:45 a.m. a CNA sitter informed an RN and LVN that the resident had removed his catheter. The charge nurse and RN found the resident in bed with profuse bleeding from the penis. The RN documented that the resident stated he had purposely pulled out his catheter because he wanted to be sent out, and the sitter witnessed the resident pull out the catheter. The MD was notified, an ambulance was called around 5:00 a.m., and the resident left the facility at 5:05 a.m. with ambulance personnel. A review of the facility’s Bed Hold Policy and Notification form for this resident indicated that the resident’s daughter was notified by phone on January 4, 2026, of the right to hold the bed for seven days and that she declined, but the form did not document the time of the call or the identity of the facility representative. In a subsequent interview, the RN Supervisor stated she did not call the resident’s daughter about the bed hold. The LVN reported that she called the daughter to inform her of the transfer to the hospital but did not inform her about the bed hold. The resident’s daughter stated she had not received any call or mail from the facility regarding the right to exercise the bed hold provision since the transfer. Review of the facility’s Bed-Holds and Returns policy, dated March 2022, with the DON and ADON showed that the policy required residents/representatives to be provided written information about bed-hold policies in advance of transfer and at the time of transfer (or within 24 hours for emergencies). The DON acknowledged the policy was not followed.
Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents. For one resident with chronic kidney disease and a history of repeated falls, the call light was observed wrapped around the left bed rail with the cord hanging down toward the floor, and the bedside table was placed against the left bed rail, obstructing access to the call light. The resident stated he was unaware of the location of the call light and could not recall the last time he experienced a fall in the facility. For the second resident, who had a nondisplaced bimalleolar fracture and a history of repeated falls, the call light was clipped to the top portion of the bed with the cord oriented away from the resident, making it unreachable. During interviews and observations, a CNA confirmed that both residents were unable to reach their call lights when asked. The CNA and LVN both stated that the facility policy requires call lights to be within reach. The DON and ADON reviewed photographic evidence and confirmed that the call lights were not accessible to the residents, acknowledging that this was not acceptable and that staff are responsible for ensuring call lights are within reach after providing care. The facility's policy was reviewed and specifies that call lights must be within easy reach when residents are in bed or confined to a chair.
Failure to Provide Continuous Respiratory Therapy Coverage
Penalty
Summary
The facility failed to provide continuous respiratory therapy coverage for 41 residents when no respiratory therapist (RT) was on duty for approximately seven hours during a night shift. Interviews with a resident and multiple staff members confirmed that the scheduled RTs called off, and no replacement was found. As a result, there was a gap in RT coverage from 10:10 PM until 4:55 AM the following morning. During this period, a resident reported that nurses were unable to operate their respiratory equipment, leading the resident to remain off the machine, although they had been suctioned before the RT left. Review of the respiratory therapist timesheets corroborated the absence of RT staff during the specified hours. The Director of Nursing acknowledged that the facility did not follow its own staffing policy, which requires sufficient numbers of staff with the necessary skills and competency to provide care in accordance with resident care plans and the facility assessment. The lack of RT coverage was confirmed by both the timesheets and staff interviews.
Failure to Ensure Timely Dialysis for Resident After Readmission
Penalty
Summary
A resident with end stage renal disease, dependent on renal dialysis, was admitted to the facility with orders for hemodialysis on specific days. The resident missed two scheduled dialysis treatments due to a failure in obtaining the necessary consent and completing required paperwork for dialysis services following a readmission from an acute hospital stay. The resident was not able to make their own decisions, and consent from the family was required but not obtained in time. As a result, the resident did not receive dialysis as ordered by the physician and was subsequently sent to an acute hospital for treatment. Interviews with facility staff revealed confusion and lack of clarity regarding the process for re-establishing dialysis services after a resident's discharge and readmission. The Admission Coordinator acknowledged not being aware that the resident needed to be treated as a new admission for dialysis purposes and did not complete the necessary paperwork or obtain consent in a timely manner. The DON confirmed that the responsibility for ensuring dialysis authorization and documentation rested with the facility, and the delay in obtaining consent led to the missed treatments.
Failure to Perform Hand Hygiene After PPE Removal in Isolation Rooms
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to perform hand hygiene after removing personal protective equipment (PPE) upon exiting the isolation rooms of two residents who were on contact precautions for multidrug-resistant organisms (MDROs). During an observation, the CNA was seen leaving the isolation room, doffing gloves and gown, but did not clean her hands afterward. The CNA explained that she did not perform hand hygiene because she believed she had not touched the resident or anything in the room. Review of the clinical records confirmed that both residents were on contact precautions due to MDROs. The Director of Nursing (DON) acknowledged that hand hygiene should have been performed after PPE removal. Facility policy and CDC guidelines both require hand hygiene as the final step after removing PPE to prevent the spread of infection.
Overdue Preventative Maintenance on Ventilators
Penalty
Summary
The facility failed to perform timely preventative maintenance on ventilators used by two residents in the Subacute Unit. During an observation, it was noted that the maintenance stickers on both ventilators indicated that their scheduled service dates had already passed—one was due for maintenance in June 2023 and the other in September 2024. Both the Assistant Director of Nursing (ADON) and the respiratory therapist acknowledged that the required maintenance was overdue. The residents involved were clinically compromised and dependent on ventilators for breathing support. Interviews with the ADON, two respiratory therapists, and the administrator revealed that the facility's policy required routinely scheduled maintenance of equipment according to manufacturer guidelines. However, all staff interviewed confirmed that this policy was not being followed. The process described involved respiratory therapists notifying the ADON or Director of Nursing (DON) when maintenance was due, after which the ADON or DON would contact an outside company to perform the service. Despite this process, the required maintenance was not completed as scheduled.
Failure to Provide Timely Incontinence Care per ADL Policy
Penalty
Summary
The facility failed to follow its Activities of Daily Living (ADLs) policy and procedure for three residents who were observed to be left soiled and wet. On April 30, 2025, observations and interviews revealed that one resident with diagnoses including encephalopathy, respiratory failure, tracheostomy status, and hypertension was found with a completely drenched brief, wet linen, and wet gown. The LVN present confirmed the resident's condition and stated that the CNA responsible was at lunch, with the last change occurring around 8 AM after a bowel movement. The CNA interviewed was unsure when the resident was last changed and acknowledged the resident was left wet for too long. The DON confirmed the resident's soiled condition and noted another resident was also found in a similar state. A second resident, with metabolic encephalopathy, chronic respiratory failure, type 2 diabetes, hypertension, and cerebral infarction, was also observed with a drenched brief and wet gown. The LVN confirmed this observation. A third resident, with cerebral infarction, acute respiratory failure, and type 2 diabetes, was found with a moderately wet brief. The CNA responsible stated that the residents were changed earlier in the morning and checked again before lunch, but both were heavy wetters and required frequent changes. The DON acknowledged that residents should be kept dry and repositioned, and that there was sufficient staff to provide care. The facility's ADL policy requires residents to receive necessary services to maintain hygiene, which was not followed in these instances.
Delayed Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete an admission Minimum Data Set (MDS) assessment for a resident within the required timeframe of 13 days after admission. The resident was admitted on February 11, 2025, but the MDS assessment was not completed until March 6, 2025, which exceeded the allowed period. The MDS Coordinator acknowledged that the assessment was late due to being busy, and the Director of Nursing confirmed that MDS coordinators are responsible for completing these assessments within the scheduled timeframes. The Administrator and the Director of Nursing both expressed expectations that MDS assessments should be completed timely, in accordance with the guidelines outlined in the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. However, the facility did not have a specific policy addressing MDS assessments, relying instead on the RAI Manual. This oversight resulted in the delayed completion of the resident's admission MDS assessment, as confirmed by interviews with facility staff.
Inaccurate MDS Discharge Coding for Resident
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment accurately reflected the location to which a resident was discharged. Specifically, for one resident, the discharge MDS was incorrectly coded to indicate that the resident was discharged to a short-term general hospital, when in fact, the resident was discharged home with hospice services. This discrepancy was identified during a review of the resident's records, which included an Admission Record, Treatment Administration Record, and Progress Notes, all indicating that the resident was discharged home with hospice services as per the family's request. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed the error in the discharge MDS coding. The MDS Coordinator acknowledged that the discharge MDS was completed incorrectly and should have been coded to reflect the resident's actual discharge to home with hospice services. The DON also confirmed the incorrect coding and stated that the MDS coordinators were responsible for completing discharge MDS assessments. The Administrator expressed an expectation for all MDS assessments to be completed accurately.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident was monitored for adverse drug reactions or side effects related to the use of a prescribed antipsychotic medication, Zyprexa. The facility's policy required nursing staff to monitor and report adverse consequences of antipsychotic medications to the attending physician. However, the resident's order summary report did not include orders for monitoring adverse drug reactions or side effects. The care plan directed staff to monitor for side effects and effectiveness each shift, but no monitoring orders were in place. Interviews with nursing staff and the Director of Nursing (DON) revealed that there were expectations for monitoring orders to accompany antipsychotic medication orders. Both Licensed Vocational Nurses (LVNs) confirmed the absence of monitoring orders for the resident's Zyprexa prescription. The DON acknowledged the importance of monitoring for potential side effects and confirmed that monitoring orders should have been initiated when the medication was ordered. The deficiency was identified when it was discovered that the resident had no side effect monitoring orders until the day before the interviews.
Failure to Disinfect Equipment Between Residents
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of supplies between resident uses, as observed during medication administration for two residents. The facility's policy on cleaning and disinfection, revised in 2018, requires that non-critical reusable items, such as clipboards, be cleaned and disinfected between residents. However, during an observation, a Licensed Vocational Nurse (LVN) did not clean or disinfect a clipboard when moving it between the beds of two residents who required contact precautions due to infections with carbapenem-resistant organisms. Resident #72, admitted in November 2022, had a medical history including tracheostomy status, gastrostomy status, and Klebsiella pneumoniae infection. The resident was noted to have a carbapenem-resistant organism and required contact precautions. Similarly, Resident #38, admitted in February 2023, had a medical history including tracheostomy status, gastrostomy status, and a persistent vegetative state, and also required contact precautions for a carbapenem-resistant infection. During the medication administration, the LVN placed a clipboard on both residents' beds without cleaning it between uses, potentially risking cross-contamination. Interviews with the LVN, Nurse Liaison, Assistant Director of Nursing, Director of Nursing, and the Administrator confirmed that the clipboard should have been disinfected between uses. The LVN acknowledged the oversight, and the facility staff reiterated the importance of using Clorox wipes for disinfection to prevent contamination and the spread of infection. The failure to adhere to the facility's disinfection policy was identified as a deficiency in infection prevention and control practices.
Prolonged Wait Times for Resident Assistance Due to Staffing Issues
Penalty
Summary
The facility failed to adhere to its Activities of Daily Living (ADLs) policy and procedure, resulting in prolonged wait times for assistance for three residents. Resident 1, who has chronic respiratory failure and is dependent on a respirator, reported waiting over an hour for assistance after using the call light. The resident also observed a respiratory therapist sleeping at the nurse station, indicating a lack of staff responsiveness. Resident 2, diagnosed with necrotizing fasciitis and acute respiratory failure, experienced similar delays, with staff turning off the call light without providing assistance, leading to waits exceeding an hour. Resident 3, who has a stage 4 pressure ulcer, also faced delays in receiving care, as staff prioritized assigned duties over immediate resident needs. Interviews with Certified Nursing Assistants (CNAs) revealed systemic issues contributing to these deficiencies. CNA1 reported receiving residents in soiled conditions from previous shifts and highlighted the challenge of managing care for 13-14 residents due to staffing shortages. CNA2 corroborated these claims, noting that management was aware of the staffing issues but failed to address them effectively. The CNAs expressed frustration over the lack of support from nurses and management, which hindered their ability to provide timely care. The Director of Nursing (DON) acknowledged the expectation for staff to respond promptly to call lights and to check on residents every two hours. However, the facility's policies on answering call lights and maintaining ADLs were not consistently followed, as evidenced by the residents' experiences and staff testimonies. The facility's failure to ensure adequate staffing and adherence to care protocols placed residents at risk for health complications, such as skin breakdown, due to unmet care needs.
Deficiency in Shower Room Maintenance and Cleanliness
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment in the shower room used by two residents. Observations and interviews revealed that the shower room had uneven flooring, fractured tiles, and permanent residue on the walls. Residents reported that the shower room was dirty, with gloves on the floor, and the shower stall was not functioning properly, lacking hot water. The Director of Maintenance acknowledged that the hot water was not checked on some days, and the Director of Housekeeping confirmed the floor's unevenness and the presence of permanent residue that could not be removed. Resident 1, who has osteomyelitis and type 2 diabetes, and Resident 2, who has chronic respiratory failure, a tracheostomy, and epilepsy, both expressed concerns about the cleanliness and condition of the shower room. The Assistant Director of Nursing noted that residents did not wear shoes or slippers when brought to the shower room, and the Director of Nursing admitted that the shower room did not appear clean. The facility's maintenance policy, dated December 2009, requires maintaining the building in compliance with laws and free from hazards, which was not adhered to in this case.
Resident Left Unattended, Resulting in Fall and Injury
Penalty
Summary
The facility failed to adhere to its safety and supervision policy when a resident, who was in a persistent vegetative state, was left unattended during care. The resident was admitted with a diagnosis that included a persistent vegetative state, indicating severe brain damage. During an incident, a CNA left the resident unattended to gather supplies, and upon returning, found the resident on the floor, undressed. This incident resulted in the resident sustaining a cut to the forehead and a dislodged G-tube, necessitating transfer to an acute general hospital for evaluation and treatment. Interviews with staff revealed that the resident had a tendency to lean forward when coughing, which was known to the nursing staff. Despite this, appropriate fall precautions and preventive measures, such as a bed alarm or relocating the resident closer to the nurses' station, were not implemented. The facility's policy on safety and supervision emphasized that resident supervision should be based on individual needs and environmental hazards, which was not adequately followed in this case.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to adhere to its policy and procedure for timely response to call lights, impacting three residents who were clinically compromised. Observations and interviews revealed that the call lights were not answered promptly, particularly during nighttime hours. Resident 1 reported that it took more than 20 minutes for staff to respond to the call light at night. Resident 2 stated that the response time was typically an hour, with delays being more pronounced at night. Resident 3 experienced an extreme delay, waiting six hours for assistance after activating the call light at 10:30 pm, which resulted in discomfort due to a sore from not having her diaper changed. The facility's staff, including CNAs and the Director of Nursing, acknowledged the delays in responding to call lights, attributing the issue to understaffing. The facility's policy, which was undated, specified that call lights should be answered within 10 to 15 minutes to ensure timely responses to residents' needs. Despite this policy, the facility's failure to provide timely assistance jeopardized the health and safety of the residents, who had significant medical conditions such as chronic kidney disease, sepsis, pulmonary hypertension, and multiple fractures of the pelvis.
Failure to Document and Address Wound Care Refusals
Penalty
Summary
The facility failed to provide proper wound care treatments and assessments for a resident, leading to a health and safety risk. The resident, who was clinically compromised with conditions such as acute kidney failure, heart failure, osteomyelitis, diabetes type II, and hypertension, was admitted with specific wound care orders. These orders included cleansing and dressing various surgical sites and monitoring for infection. However, the treatment nurse reported that the resident refused wound care for three consecutive days, and the nurse only observed the wounds without performing the necessary treatments. The nurse documented the refusals in the care plan but failed to record them in the progress notes or notify the physician properly. The nurse claimed to have informed the nurse practitioner via a message but did not receive a response and continued to monitor the situation without further documentation. The Director of Nursing (DON) was unaware of the refusals until later, and the Treatment Administration Record (TAR) was inaccurately marked as if the treatments were completed, despite the resident's refusals. The facility's policies on wound care and documentation require detailed recording of wound care provided, changes in the resident's condition, and any refusals of treatment. However, these procedures were not followed, as there was no documentation of the refusals in the progress notes, no follow-up assessments, and no proper notification of the physician. This lack of documentation and communication contributed to the resident's condition worsening, resulting in an infection and subsequent hospital stay.
Neglect in Comprehensive Assessment Leads to Resident's Death
Penalty
Summary
The facility failed to protect a resident from neglect when Registered Nurses did not perform a comprehensive nursing assessment upon the resident's initial admission and subsequent readmission from the hospital. This oversight led to a critical error where a Registered Nurse connected the enteral feeding formula to the resident's paracentesis drainage tube instead of the gastrostomy tube. As a result, the resident experienced severe abdominal pain due to the enteral feeding formula being administered into the peritoneal cavity. The resident, who had multiple complex medical conditions including cardiac arrest, end-stage renal disease, liver cirrhosis, and dependence on a tracheostomy and gastrostomy tube, was admitted to the facility without a comprehensive assessment being documented. The lack of a thorough assessment meant that the presence of a paracentesis drainage tube was not noted, leading to the critical error in administering the enteral feeding formula. The error was discovered when the resident's wife reported abdominal pain, prompting an assessment that revealed the feeding formula was incorrectly connected. The resident was transferred to a general acute care hospital, where he was diagnosed with septic shock and peritonitis, ultimately leading to his death. The facility's failure to conduct a comprehensive assessment upon admission and readmission directly contributed to this tragic outcome.
Removal Plan
- In-Service was conducted by the DON and Assistant director of Nursing (ADON) regarding new admissions and readmissions to be assessed by RN upon admission/arrival to include head to toe assessment as soon as practically possible or within the first 2 hours from the time of admissions to assess stability of the resident, with documented evidence of full assessment by the end of the shift and according to the regulatory standards.
- In-Service was conducted by the DON and ADON regarding Licensed staff including RNs will be educated by DON or Designee on the assessment process to ensure compliance prior to starting shifts. Ongoing training will be provided via verbal education and skills-check to existing and new staff, as needed and upon orientation, respectively, to ensure compliance. Onboarding Licensed staff and staff who are away will also be oriented of the proper procedures, with documented evidence accordingly, prior to beginning shift/ floor duties.
- In-Service was conducted by the DON and ADON regarding the policy and procedures of Admission Evaluation / Assessment & Follow-up: Role of Nurse.
Nursing Competency Deficiency Leads to Fatal Tube Misconnection
Penalty
Summary
The facility failed to ensure that licensed nurses were adequately trained and competent in managing paracentesis drainage tubes and gastrostomy tube feeding. This deficiency was highlighted when a registered nurse mistakenly connected and infused enteral feeding formula into a paracentesis drainage tube instead of the gastrostomy tube for a resident. This error resulted in the resident experiencing unnecessary abdominal pain and the retention of enteral feeding formula in the peritoneal cavity, leading to the resident's transfer to a general acute care hospital's intensive care unit, where the resident subsequently died. The resident involved had a complex medical history, including cardiac arrest, end-stage renal disease with hemodialysis, liver cirrhosis, diabetes mellitus type 2, tracheostomy status, and gastrostomy status. The resident was dependent on a ventilator and renal dialysis and had a paracentesis drainage tube and gastrostomy tube. The incident occurred when the resident's wife requested a charge nurse to connect a drainage bag to the paracentesis tube. Upon assessment, it was discovered that the enteral feeding formula was mistakenly infused into the paracentesis drainage tube, which was not properly connected, leading to the resident's severe abdominal pain and subsequent hospitalization. Interviews with nursing staff revealed a lack of specific training and competency in managing paracentesis drainage tubes. Several nurses, including licensed vocational nurses and registered nurses, admitted to receiving general training on drainage tubes but not specifically on paracentesis drainage tubes. The Director of Nursing confirmed that the facility's policy on managing drainage tubes was not followed, and no prior training on paracentesis drainage tubes had been conducted before the incident. This lack of training and competency directly contributed to the misconnection error and the resident's adverse outcome.
Removal Plan
- In-service conducted by Director of Nursing on proper infusion of G-tubes and management of drainage tubes including paracentesis drainage tubes.
- Monitoring of the G-tube feeding by licensed staff per shift to verify pump has been infused properly.
- Observe the status of the resident and ensure resident's needs are met.
- As safety precaution, 2 nurses will check to verify G-tube feedings for accuracy and compliance at the change of shift.
- Ongoing education and competency training to be provided to staff to verify competency of the licensed staff particularly as it relates to proper infusion and monitoring of G-tube feeding and managing paracentesis drainage tubes.
- Onboarding licensed staff and staff who are away will also be oriented of the proper procedures with documented evidence accordingly prior to beginning shift/floor duties.
- In-service conducted by DON and Assistant Director of Nurses regarding identifying the different types of enteral feeding, enteral tube use and maintenance, tube occlusion: prevention/management, G-tube replacement, and patency.
Delayed Response to Call Lights for Two Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure for providing timely responses to call lights, affecting two out of four sampled residents. Resident 1, who was admitted with a diagnosis including unspecified hyperlipidemia, reported that staff responses to call lights were delayed, particularly during the night shift, sometimes taking an hour or two. This resident also mentioned infrequent repositioning, which is crucial given their self-care deficit related to deconditioning. The care plan for Resident 1 emphasized the importance of promptly responding to call lights, yet this was not consistently followed. Similarly, Resident 2, who has multiple health conditions including chronic kidney disease stage 5, hypertension, and obstructive sleep apnea, also experienced delays in call light responses, sometimes waiting 30 minutes or longer. This resident faced challenges in receiving timely assistance with turning, meal requests, and shower schedules. The care plan for Resident 2 also highlighted the need for prompt response to call lights, which was not met. The facility's policy titled 'Answering the Call Lights' was not effectively implemented, as evidenced by the residents' experiences.
Failure to Prevent Pressure Ulcer in Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for the prevention of pressure ulcers, resulting in a deficiency. A resident, who was admitted with no initial pressure ulcers, developed a stage 4 pressure ulcer on their back while in the facility's care. The resident reported that staff responses to call lights were delayed, particularly during the night shift, and that repositioning was not performed regularly as required. The facility's policy mandates repositioning every two hours for residents dependent on staff for mobility, which was not followed in this case. The resident required maximum assistance for bed mobility, as indicated in the Physical Therapy Discharge Summary. Despite this need, the resident was not repositioned adequately, leading to the development of a severe pressure ulcer. The wound care nurse confirmed that the ulcer was acquired at the facility and was not present during the initial assessment. The failure to reposition the resident as per the facility's policy directly contributed to the development of the pressure ulcer.
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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.
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Nursing homes near Colton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadows Ridge Care Center | 0.6 mi | ★★★★★ | 8 | 0 |
| Grand Terrace Health Care Center | 1.3 mi | ★★★★★ | 5 | 0 |
| Heritage Gardens Health Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Loma Linda Post Acute | 2.4 mi | ★★★★★ | 0 | 0 |
| Totally Kids Rehabilitation Hospital - D/p Snf | 3.4 mi | ★★★★★ | 10 | 0 |
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