Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Canyon Transitional Rehabilitation Center, Llc during CMS and state inspections, most recent first.
Incomplete food safety logs and improper food handling were observed in the kitchen and nourishment room. Required sanitizer bucket, 3-compartment sink, dish machine, and refrigerator/freezer temperature logs were not consistently completed, open food items were left exposed in the freezer, raw meat was stored above prepared pudding cups in the refrigerator, and a DM handled a chicken sandwich with bare hands while checking its temperature.
CNA In-Service Training Deficiency: The facility failed to ensure 4 of 7 CNAs reviewed completed the required 12 hours of annual in-service training. Record review showed several CNAs received only partial training hours, and the DON confirmed the shortfalls and stated CNA education had been managed by the DON and Unit Manager.
Failure to develop a care plan for a resident's behavioral health needs and SI. A resident with dementia, cognitive impairment, and moderate depression made a statement about hurting herself, later denied active SI, and had ongoing anxiety, insomnia, and increased behavior symptoms. Although an IDT review included an ASAP psych service order, the care plan did not address the resident's dementia-related behaviors or psychiatric service needs, and the DON confirmed the omission.
A resident with dysphagia, aphasia, and malnutrition was sent to the hospital for poor nutritional status and later returned with a feeding tube and NPO orders. The care plan was updated to include enteral feeding, but it still retained an active impaired swallowing focus with dining assistance interventions. The DON stated the swallowing focus should have been shown as resolved and that feeding assistance should not have remained on the care plan.
A resident received Tylenol from an OTC bottle that did not have a manufacturer expiration date or a date of opening on the label. The CMA stated OTC meds should have both dates and acknowledged he should have obtained a new bottle instead of using the undated one. The DON stated staff are expected to check OTC expiration dates and not use a bottle without one.
The facility failed to maintain infection control for two residents. A resident with an indwelling urinary catheter was observed with the drainage bag and tubing hanging from a wheelchair and touching the floor, despite staff expectations that it remain below the bladder and off the floor. Another resident with COPD and continuous oxygen was observed with the oxygen humidification container on the floor, and it remained there on repeat observation; an LPN and the DON both stated this was not appropriate because it is an infection control issue.
The facility's kitchen was found unsanitary due to improper food storage and labeling. Observations revealed undated and expired food items, improperly sealed deli ham, and leaking ham juice contaminating other foods. Staff interviews confirmed these issues, with the kitchen manager attributing the state to staff rushing. A prior audit by the interim dietician also noted unlabeled food.
The facility failed to notify the physician for two residents experiencing significant issues: one in severe pain and another missing several doses of an IV antibiotic. The staff did not document or communicate these issues, leading to a lack of prompt medical intervention.
A resident with a history of severe malnutrition and gastrostomy status experienced a clogged g-tube, which the facility staff failed to unclog despite multiple attempts using various methods. The resident was transferred to the hospital, where the g-tube was successfully unclogged by interventional radiology. The facility's actions did not align with professional standards and their own policies, leading to a deficiency.
A facility experienced a high medication error rate of 48.75% due to late administration and lack of communication with residents about their medications. Nurse #1 administered medications late to several residents due to staffing issues and did not inform them about the medications being given. Additionally, a resident missed a dose of vancomycin due to pharmacy delivery issues, highlighting a breakdown in the facility's medication management system.
A resident missed several doses of vancomycin due to the pharmacy not delivering the medication and a clogged PICC line. Despite calls to the pharmacy and attempts to unclog the line, the issues persisted. The DON and NP were not informed in a timely manner, leading to a lack of coordination in addressing the problem.
The facility failed to properly label and store medications, leading to deficiencies. Observations revealed an open Lispro insulin vial and Vancomycin syrup without opening dates in the medication refrigerator, and a multivitamin bottle on a medication cart belonging to discharged residents. The Nurse Manager and a CMA confirmed these oversights, which could result in residents receiving less effective or expired medications.
The facility failed to maintain a clean and homelike environment for residents on the 400 hall, where a strong odor of urine and feces was present. A resident with a bedside commode often left the lid open, contributing to the smell. A CNA confirmed this practice, and another resident reported being bothered by the odors.
A resident's advance directive was incomplete as the Medical Orders for Scope of Treatment (MOST) form was not signed, despite the resident electing a do not resuscitate (DNR) status. The Director of Nursing confirmed the oversight.
The facility failed to complete comprehensive care plans for two residents, affecting areas such as ADL care, psychotropic medication use, and management of medical conditions like diabetes and cardiovascular symptoms. The care plans lacked specific goals and interventions, which could impact the staff's ability to provide adequate preventative care. The Director of Nursing confirmed the incompleteness of these care plans.
A resident experienced significant pain despite being administered Tylenol, which was ineffective. The resident requested additional pain medication, but the nurse did not notify the physician or document the change in condition. The Unit Manager confirmed that staff should have documented the issue and informed the physician.
A nurse failed to perform hand hygiene before and after administering medications to a resident, potentially risking the spread of infectious agents among 23 residents in the facility. The nurse acknowledged the oversight during an interview.
Incomplete Food Safety Logs and Improper Food Handling
Penalty
Summary
Food was not prepared, served, handled, and monitored under sanitary conditions because required kitchen and nourishment room logs were not completed. Record review showed the sanitizer bucket log was not documented on 02/01/26, 02/07/26, and 02/08/26; the three-compartment sink log was documented for only one day during 02/07/26 through 02/22/26; the dish machine log was not documented on 02/07/26, 02/08/26, and 02/16/26; and the nourishment room refrigerator and freezer temperature logs were not documented from 02/14/26 through 02/26/26. During interview, the District Dietary Manager stated kitchen staff were responsible for completing all logs and acknowledged the logs were not completed. Kitchen observations also showed improper food storage and handling. A small box of crab cakes and a medium box of corn were open and exposed to the air inside the large freezer, and a medium package of raw meat was stored above prepared pudding cups on a speed rack inside the large refrigerator. During a lunch test tray observation, the Dietary Manager obtained the temperature of a chicken sandwich without wearing gloves and touched the bun with bare hands. The District Dietary Manager stated it was her expectation that food be properly stored, meats not be stored above prepared foods, and gloves be worn while obtaining food temperatures, and she identified E. coli as a possible risk to residents as a result.
CNA In-Service Training Deficiency
Penalty
Summary
The facility failed to ensure Certified Nurse Aides (CNAs) received at least 12 hours of required annual in-service training for 4 of 7 CNAs reviewed. Record review of the CNA staffing and training log showed that CNA #12, hired on 03/24/25, completed only 7 hours 52 minutes of in-service training; CNA #13, hired on 09/30/24, completed only 4 hours 11 minutes; CNA #16, hired on 04/22/15, completed only 4 hours 44 minutes; and CNA #17, hired on 05/30/24, completed only 5 hours. During interview, the DON stated the facility had never had a nurse educator, that one had been hired and would start soon, and that she and the Unit Manager had been managing CNA education. The DON confirmed that CNAs #12, #13, #16, and #17 did not complete the required 12 hours of in-service training and should have.
Failure to Develop Care Plan for Behavioral Health Needs and Suicidal Ideation
Penalty
Summary
The facility failed to develop an accurate, comprehensive, person-centered care plan for a resident admitted on 01/18/26. Nursing progress notes documented that on 01/19/26 the resident made a comment about hurting herself to staff, then denied active suicidal ideation when followed up by the nurse and supervisor, stating she was frustrated and did not think she would be able to follow through with hurting herself. On 01/20/26, the interdisciplinary team reviewed orders, including a new order for psychiatric services ASAP related to suicidal ideation. Subsequent notes on 01/21/26 documented anxiety, a desire to go home, and increased behavior symptoms with poor sleep due to insomnia. Record review showed the resident had cognitive impairment, with a BCAT score of 20 on 01/20/26, and an admission MDS dated 01/22/26 documented dementia and a PHQ-2 to 9 total severity score of 10, indicating moderate depression. The MDS also reflected multiple depressive symptoms, including little interest or pleasure, feeling down or hopeless, feeling bad about herself, trouble concentrating, slowed movement or restlessness, and sometimes feeling lonely or isolated. Despite these behavioral health findings and the psychiatric service order, the care plan dated 01/25/26 did not address the resident's dementia-related behaviors or psychiatric service needs. During observation on 02/25/26, the resident was sitting alone in her room and declined to be interviewed, with signs of emotional withdrawal present. The DON later confirmed that the care plan should have addressed the resident's behavioral concerns and suicidal ideation, and that it had not been developed to do so.
Care plan not updated after feeding tube placement
Penalty
Summary
The facility failed to revise R #70’s care plan after the resident’s swallowing status changed and a feeding tube was placed. R #70 was admitted with diagnoses including dysphagia, aphasia, and malnutrition. Nursing progress notes dated 02/04/26 documented that the resident was sent to the hospital because of poor nutritional status related to dysphagia, poor intake was affecting wound healing, and a FEES test showed a risk of silent aspiration. The facility was seeking a hospital assessment for possible feeding tube placement so the resident could receive proper nutrition. R #70 was readmitted to the facility with a feeding tube, and physician orders dated 02/13/26 directed enteral feeding, water flushes before and after feeding, continuous feeding at 45 ml per hour, and NPO status. The care plan still contained a focus dated 01/01/26 for impaired swallowing related to stroke with dining assistance interventions, and that focus remained current as of 02/27/26. Although a separate care plan focus dated 02/23/26 addressed enteral feeding tube use, the impaired swallowing care plan was not updated to remove the feeding assistance interventions. During interview, the DON stated that if the impaired swallowing focus was no longer relevant, it should be shown as resolved and no longer active, and that since R #70 used a feeding tube, there should not be a care plan present for feeding assistance.
Medication Given From OTC Bottle Without Required Dating
Penalty
Summary
A significant medication error occurred when Tylenol (acetaminophen) was administered to a resident during medication administration even though the bottle did not have a manufacturer’s expiration date or a date of opening on it. During the observation, the CMA prepared the resident’s Tylenol and gave it without either date being present on the bottle or label. During interview, the CMA stated that OTC medications like Tylenol can be used for 30 days after opening and that all bottles should have a manufacturer’s expiration date and a date the bottle was opened by staff. The CMA verified that neither date was on the bottle and stated he should have obtained a new bottle instead of using it. The DON stated it was her expectation that staff check the expiration date on OTC medications, and if an OTC medication does not have an expiration date, it should not be used and a new bottle should be obtained.
Infection Control Lapses With Catheter and Oxygen Equipment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infectious agents and communicable diseases for two residents. For one resident with chronic kidney disease and an active order for an indwelling urinary catheter, staff did not keep the catheter drainage bag and tubing off the floor. During a dining room observation, the resident was seated in a wheelchair eating lunch while the catheter drainage bag and attached tubing were hanging from the wheelchair and touching the floor. The DON stated catheter bags should be positioned under the resident's wheelchair and not touching the floor, and that staff are expected to ensure proper positioning. For another resident with COPD and an active order for oxygen at 1 to 6 liters per minute via nasal cannula continuously, an oxygen humidification container connected to the nasal cannula was observed on the floor of the resident's room. A repeat observation later the same day showed the humidification container remained on the floor. An LPN stated oxygen humidification should not be placed on the floor because it is an infection control issue, and the DON stated it was her expectation that the oxygen equipment should not be placed on the floor and that doing so poses a risk of infection for the resident.
Sanitation Deficiency in Kitchen Management
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during a walk-through of the kitchen refrigerator. Multiple food items were found either not dated or past their use-by date, including unidentified sandwiches, mashed potatoes, egg salad with unclear dates, and sliced cheese that was hard and discolored. Additionally, a container of deli ham was not sealed, and a large container of leftovers was neither labeled nor dated. Ham stored in a cardboard box was placed on a shelf above the leftovers, and juice from the ham leaked onto the foil covering the leftovers. Interviews with kitchen staff revealed further issues. A kitchen assistant acknowledged the presence of unlabeled food and confirmed that the juice on the leftovers was from improperly stored ham. The kitchen manager admitted that the staff left the kitchen in disarray after the weekend, suggesting they were in a rush. An interim registered dietician reported conducting a sanitary audit of the kitchen prior to these observations and found unlabeled food in the refrigerator.
Failure to Notify Physician of Pain and Missed Medication Doses
Penalty
Summary
The facility failed to notify the physician or nurse practitioner for two residents experiencing significant medical issues. One resident was in severe pain, rated at an 11 on a scale of 1 to 10, and was only administered Tylenol, which was ineffective. Despite the resident's request for additional pain relief and the nurse's awareness of the situation, no further action was taken to notify the physician or obtain an alternative pain management order. The staff did not document any further progress notes or notify the physician about the resident's unrelieved pain, which was a deviation from expected protocol. Another resident missed several doses of a prescribed intravenous antibiotic, vancomycin, due to the medication not being delivered by the pharmacy. The nursing staff failed to inform the nurse practitioner about the missed doses, which could have prompted further medical intervention or adjustments in treatment. The nurse practitioner only became aware of the missed doses through an on-call provider's report days later. The lack of communication and documentation regarding the missed medication doses was a significant oversight in the resident's care management.
Failure to Maintain and Care for Resident's Gastrostomy Tube
Penalty
Summary
The facility failed to provide care that met professional standards for a resident with a gastrostomy tube (g-tube), leading to a deficiency. The facility's policy on enteral management and medication administration through enteral tubes was not adhered to, as evidenced by the inability to unclog the resident's g-tube. The resident, who had a history of severe protein-calorie malnutrition, aphasia, dysphasia, dysarthria, and gastrostomy status, experienced a clogged g-tube. Despite attempts by the staff to unclog the tube using various methods, including warm water, carbonated beverages, and pressure, they were unsuccessful. The staff also used a declogger wand and soda, which the Director of Nursing later acknowledged might not be considered best practice. The resident was eventually sent to the emergency room for further evaluation and treatment. At the hospital, the g-tube was unclogged using a syringe with pressure by interventional radiology. The resident was stable and discharged back to the facility. The report highlights that the facility's failure to effectively manage the resident's g-tube according to professional standards and facility policy resulted in the resident being transferred to the hospital for a procedure that could have been avoided with proper care.
High Medication Error Rate Due to Late Administration and Communication Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a significantly high error rate of 48.75% during medication administration for 7 out of 11 residents reviewed. This deficiency was observed during a survey where staff administered 80 medications with 39 errors. The errors were primarily due to late administration and lack of communication with residents about their medications. Nurse #1 was observed administering medications late to several residents, including R #25, R #32, R #317, R #130, R #131, and R #132. The delay was attributed to the absence of a Certified Medication Aide, which led to Nurse #1 covering additional duties. During the administration, Nurse #1 did not inform residents about the medications they were receiving, which is a critical step in ensuring residents are aware of their treatment and can report any issues or side effects. Additionally, there was a failure in medication delivery from the pharmacy, as noted with R #132, who missed a scheduled dose of vancomycin due to non-delivery. This highlights a breakdown in the facility's medication management system, contributing to the high error rate. The facility's staff, including Nurse #4, acknowledged the requirement to administer medications within a two-hour window, yet this standard was not met, further exacerbating the issue.
Failure to Administer Vancomycin Timely Due to Pharmacy and PICC Line Issues
Penalty
Summary
The facility failed to administer vancomycin, an antibiotic medication, to a resident in a timely manner as per the physician's order. The resident, who was admitted with multiple diagnoses including osteomyelitis of the vertebra, discitis, and bacteremia, missed several doses of vancomycin due to the medication not being delivered by the pharmacy and issues with the resident's PICC line. The resident's Medication Administration Record indicated missed doses on multiple occasions due to these issues. Nurse #1 observed that the vancomycin was not available because the pharmacy did not deliver it, despite her calls to the pharmacy. Additionally, the resident's PICC line was clogged, preventing the administration of the medication. A specialized nurse attempted to unclog the line but was unsuccessful, and a new PICC line was needed. The Director of Nursing was unaware of the situation, and the Nurse Practitioner was not informed of the missed doses until reviewing the on-call provider's report. The lack of communication and coordination among the nursing staff, pharmacy, and specialized nurses contributed to the failure to administer the medication as ordered. The Director of Nursing stated that if she had been informed, she would have taken steps to address the issue, including checking the medication room stock and contacting the pharmacy and specialized team. The Nurse Practitioner also indicated that he would have taken action if notified, such as contacting the Infectious Disease Team and ordering a vancomycin trough blood level test.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which led to several deficiencies. During an observation of the medication refrigerator, it was found that a Lispro insulin vial and a Vancomycin syrup bottle were open without an opening date. The insulin vial belonged to a resident who was actively receiving it, while the Vancomycin syrup belonged to a resident who had been discharged. The manufacturer's instructions for Lispro insulin require that opened vials be discarded after 28 days, but this was not adhered to. The Nurse Manager confirmed that staff are required to date opened insulin vials and discard medications belonging to discharged residents. Additionally, an observation of a medication cart revealed an open multivitamin bottle that was not dated and belonged to a discharged resident. A CMA acknowledged that the multivitamin should have been removed from the cart following the resident's discharge. These practices could result in residents receiving less effective or expired medications, affecting all 70 residents in the facility.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for the 21 residents living on the 400 hall. During an initial tour, a strong odor of urine and feces was detected throughout the hallway. A resident with a bedside commode admitted to not always closing the lid after use, which contributed to the odor. Observations confirmed that the commode was left open with urine inside. A CNA corroborated that the resident's habit of leaving the commode lid open was a source of the hallway's urine smell. Another resident expressed discomfort due to the persistent odors in the hallway.
Incomplete Advance Directives for a Resident
Penalty
Summary
The facility failed to ensure that advance directives were complete for a resident reviewed for advance directives. Specifically, the resident had elected a do not resuscitate (DNR) status, which is a medical order instructing healthcare providers not to perform cardiopulmonary resuscitation (CPR) if the patient's heart stops beating or breathing stops. However, the Medical Orders for Scope of Treatment (MOST) form, which serves as an advance directive, was not signed by the resident. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the form should have been signed by the resident but was not.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to complete comprehensive care plans for two residents, which could potentially affect the staff's ability to implement preventative measures for the residents' health and well-being. For Resident #23, the care plans were incomplete in areas such as activities of daily living (ADL) care, psychotropic medication use, and respiratory complications. The care plan lacked detailed goals and interventions, such as the number of days the resident would not exhibit signs of respiratory distress. The resident had multiple diagnoses, including muscle weakness, lack of coordination, and respiratory failure with hypoxia, and was on several psychotropic medications. Similarly, for Resident #166, the care plans were incomplete in areas including ADL care, cardiovascular symptoms, diabetes management, and anticoagulant medication use. The care plan did not specify goals such as the number of days without signs of hypo/hyperglycemia or bleeding due to anticoagulation therapy. This resident had a complex medical history, including type 2 diabetes with complications, cerebrovascular disease, and a history of venous thrombosis. The Director of Nursing acknowledged that the care plans for both residents were incomplete.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate and timely pain relief for a resident, identified as R #29, who was experiencing significant pain. On the morning of 11/25/24, R #29 was observed rubbing her hand and crying, indicating a high level of pain. She reported to a CNA that the Tylenol she had been given was ineffective and requested medication for her nerve pain. The CNA informed the nurse, but the nurse stated that R #29 only had Tylenol prescribed for pain and was not due for another dose. The nurse did not notify the physician about the resident's ongoing pain or the ineffectiveness of the medication. The medical records showed that R #29's pain level was documented as a 10 out of 10 shortly before the Tylenol was administered, and staff later noted that the medication was ineffective. Despite this, no further action was taken to address the resident's pain, and there was no documentation of notifying the physician or making a progress note about the change in the resident's condition. The Unit Manager later confirmed that staff should have documented the change in condition and notified the physician when the Tylenol was found to be ineffective.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection prevention practices when a nurse did not perform hand hygiene before and after handling medications for a resident. During an observation, Nurse #1 was seen administering medications without performing hand hygiene, which includes hand washing, antiseptic handwash, or using an alcohol-based hand rub. In a subsequent interview, Nurse #1 acknowledged that she should have performed hand hygiene both prior to and after administering medications. This deficient practice could likely result in the spread of infectious agents among the 23 residents in the 100 hall.
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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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How nearby facilities compare on the same public inspection record.
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| La Vida Llena | 0.6 mi | ★★★★★ | 11 | 0 |
| Bear Canyon Rehabilitation Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Sandia Ridge Center | 2 mi | ★★★★★ | 11 | 0 |
| Uptown Rehabilitation Center | 3.1 mi | ★★★★★ | 1 | 0 |
| Las Palomas Center | 3.3 mi | ★★★★★ | 14 | 6 |
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