Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Vista Post Acute during CMS and state inspections, most recent first.
A resident’s meds were left on a breakfast tray and charted as given without direct observation of ingestion, another resident’s meds were pre-charted before administration and later partially refused/spit out, and a resident with bilateral nephrostomy tubes had wound care documented as completed even though it was not actually provided. The DON confirmed the RN and wound care nurse did not follow facility medication administration and documentation policy, resulting in records that did not match the care actually delivered.
A resident with CKD stage 4 and bilateral nephrostomy tubes had ordered site care that was not followed as documented. Staff signed off nephrostomy cleansing and dressing changes in the MAR before actually performing the care, and the wound care nurse later acknowledged the entry was inaccurate when the resident refused care. The DON confirmed the documentation did not match the care provided, and the lead wound nurse stated this placed the resident at risk for infection.
Expired and unlabeled food items were found in 3 of 4 nourishment room refrigerators, including resident food with past expiration dates and an unlabeled resident item. The ADON, RN, CNAs, and DON confirmed the items should have been labeled and/or discarded, and staff stated nourishment refrigerators were checked daily or twice daily for expired items.
Trash Compactor Not Kept in Sanitary Condition: Surveyors observed the kitchen trash compactor had a foul odor, leaks along the side and bottom, and accumulated liquid waste. The head cook confirmed the leak and odor, the Maintenance Director verified the leak and said the unit needed replacement, and the ADON stated the compactor was not sanitary and could create a pest concern. The facility policy required garbage disposal areas and refuse containers to be free from odors and kept in good condition.
PPE Not Available in Laundry Room: Gowns were not available in the laundry room for staff handling soiled linens. A laundry aide confirmed gowns had to be obtained from another area of the facility, and the IP acknowledged the gowns should have been accessible to protect staff and prevent contamination. The facility had multiple current resident infections, including C. diff, wound infections, and cellulitis, and facility policy required staff sorting or washing linen to wear gowns and gloves.
The facility did not have a defined time frame in its Release of Information policy for providing medical records when requested. A home health agency made two requests for a resident's records, which were eventually sent electronically, but there was no documentation of the requests or calls, and the policy lacked specific processing time frames.
A resident with multiple serious diagnoses was discharged without receiving a documented medication list or education about their medications. Staff interviews confirmed that it was the nurse's responsibility to provide and review discharge instructions, including medications, but no documentation was available to show this occurred, in violation of facility policy.
The facility failed to enforce its non-smoking policy and remove smoking materials from residents, posing a fire hazard. A resident was found with a lighter and cigarettes, attempting to dispose of a used cigarette in a trash can with combustible materials. Another resident, a documented smoker with an oxygen concentrator, was involved, and a third resident admitted to smoking with the first resident. The facility did not have smoking care plans for these residents, despite their histories of substance dependence and mental health issues.
The facility failed to properly label and discard opened food items in the refrigerator and freezer, as observed by a surveyor and confirmed by the Director of Dietary Services. Items such as chopped onions, a half-cut tomato, and canned fruits were not labeled or dated correctly, and an undated chocolate cream pie was improperly stored. The dietary staff were responsible for ensuring proper labeling and timely discarding of opened items, as per facility guidelines.
The facility failed to implement baseline care plans for residents within 48 hours of admission. Four residents who smoked did not have smoking care plans, despite documentation of tobacco use. Two residents with language barriers lacked communication care plans, hindering effective communication. Additionally, a resident with an IV catheter did not have a care plan, increasing infection risk. The DON acknowledged these oversights, which were confirmed through interviews and record reviews.
The facility did not develop smoking care plans for three residents identified as tobacco users, despite their MDS assessments indicating current tobacco use. The facility's non-smoking policy led to the assumption that such care plans were unnecessary, resulting in a lack of documented focus, goals, and interventions for these residents, who had significant medical histories.
The facility failed to respond promptly to call lights, affecting multiple residents. A resident waited over an hour for pain medication after activating the call light, while another resident's cries for help were ignored for 15 minutes. Staff acknowledged issues with the call light system and ongoing QAPI projects to address response times.
A resident with acute kidney failure and obstructive uropathy had a Foley catheter that did not match the physician's order, leading to a deficiency. The physician ordered a 14 French catheter, but a 16 French catheter was used instead. This discrepancy was confirmed by an LPN and the ADON, highlighting the importance of following orders to prevent complications.
A resident experienced severe weight loss without a nutritional assessment or interventions upon admission, despite being cognitively intact. The facility's policies on nutritional assessment and weight intervention were not followed, leading to a lack of documented evidence of a nutritional care plan or dietary consultation.
A facility failed to follow tube feeding orders for a resident with dysphagia, resulting in a significant discrepancy in the total dose volume consumed. The resident, at risk for malnutrition, was observed with the enteral pump turned off during the day, despite orders for nocturnal feeding. The RD and LPN confirmed a shortage of 1269 mL and 1800 calories over 72 hours, impacting wound healing and recovery. The RN and DON acknowledged the lack of monitoring and documentation of the resident's nutritional intake.
The facility failed to obtain physician's orders and document IV access for two residents, leading to prolonged use of IV sites without proper monitoring or assessment. One resident had an IV heplock in place for 10 days without documentation, while another had a peripheral IV access for 11 days without orders or monitoring. Facility policies required orders and documentation, which were not followed, increasing infection risk.
The facility failed to consistently assess, manage, and document pain management for two residents, leading to inadequate pain relief. One resident, post-back surgery, reported severe pain and insufficient medication, with no documented assessments in the eMAR. Another resident, with a history of gout and diabetes, experienced severe pain and distress, with delayed response and undocumented medication administration. Staff interviews confirmed the lack of adherence to pain management policies, resulting in unrelieved pain and discomfort.
The facility exceeded the acceptable medication error rate with two errors during a medication pass. One resident received an incorrect dosage of Folic Acid, while another had their Cardizem withheld due to a misunderstanding of blood pressure parameters. The LPN involved acknowledged the errors, and the DON emphasized the importance of following medication administration guidelines.
The facility failed to maintain a functional call light system in the 200 hall, leading to delayed responses to residents' needs. A resident waited 25 minutes for assistance due to a malfunctioning system that produced a constant alarm sound, masking actual alerts. The issue was not reported in the maintenance log, and the facility lacked a specific policy for call light system maintenance.
Medication Documentation and Nephrostomy Care Errors
Penalty
Summary
Medications were left on a resident’s breakfast tray and documented as administered without direct observation of ingestion. The resident had diagnoses including transient cerebral ischemic attack and polyneuropathy and was observed eating breakfast with a medication cup containing eight pills on the meal tray. The resident stated the nurse left the medications there so they could take them when ready, and the assigned RN acknowledged leaving the medications on the tray and documenting them as given. The RN also stated this was not the first time doing this for the resident because it was the resident’s preference. Medications were also pre-charted as administered before actual administration for another resident. During a medication pass observation, the RN dispensed routine medications and poured 60 milliliters of Med Pass 2.0, then clicked the administered button for each medication in the resident’s EHR before entering the room. After entering the room, the resident refused the nutritional supplement and later spit out the pills after taking them with water. The RN acknowledged clicking administered before the medications were actually given and stated that refusals and spitting out could occur, making the record inaccurate. The DON confirmed the RN did not follow facility medication administration policy, and a survey-ready document on the medication cart instructed staff to stay until all medications were taken and chart after giving medication. Nephrostomy care was documented as completed without actual provision of care for a resident with acute kidney failure, chronic kidney disease stage four, and artificial openings of the urinary tract. The resident had bilateral nephrostomy tubes with dressings in place, including one dressing dated several days earlier and another undated dressing, with a dark green stain observed at one insertion site. Physician orders required cleansing both nephrostomy sites and applying dressings on specified days, and the MAR showed staff signed off that the care was completed. The wound care nurse acknowledged signing off on the cleansing and dressing changes before performing the task and later stated the care was not modified when the resident refused. The DON confirmed the care should not have been documented as performed when it was not actually provided.
Nephrostomy Care Was Documented as Completed Without Being Performed
Penalty
Summary
The facility failed to follow physician orders for nephrostomy tube care for a resident with acute kidney failure, chronic kidney disease stage four, and artificial openings of the urinary tract. The resident had bilateral nephrostomy tubes on the lower back. On observation, the left nephrostomy tube was covered with a white dressing dated 03/30/2026 and had a small dark green stain at the insertion site, while the right nephrostomy site was covered with an undated white dressing. The physician orders dated 03/01/2026 directed staff to cleanse both the right and left flank nephrostomy sites with normal saline, pat dry, apply drain cover and Tegaderm, every day shift on Mondays and Saturdays and as needed for wet or dislodged dressings. The April 2026 MAR showed staff signed off that the cleansing and dressing changes for both nephrostomy sites were completed on 04/04/2026. However, the lead wound nurse stated the wound care team was responsible for nephrostomy care and could not explain why the care was signed off when the dressing on the left site was still dated 03/30/2026. The wound care nurse acknowledged signing off on the cleansing and dressing changes before performing the task and later stated the MAR entry was not modified when the resident refused care. The lead wound nurse confirmed the care was inaccurately recorded as performed when it was not, and the DON stated the nurse should not have documented the care as completed without actually providing it. The lead wound nurse stated this practice placed the resident at risk for infection of the nephrostomy site.
Expired and Unlabeled Food Found in Nourishment Room Refrigerators
Penalty
Summary
The facility failed to ensure food items in 3 of 4 nourishment room refrigerators were properly dated, labeled, and discarded when expired. During observations on 04/07/2026, surveyors found resident food items in the 400-hall nourishment room refrigerator with an expiration date of 03/03/2026, a resident food item in the 100-hall nourishment room refrigerator with an expiration date of 04/03/2026, an unlabeled resident food item in the same refrigerator, and six milk cartons in the hall-200 nourishment room refrigerator with an expiration date of 03/05/2026. Later interviews confirmed the items should have been discarded or labeled before being placed in the refrigerator. The ADON verified the expired resident food should have been discarded and stated the unlabeled items should have been labeled before refrigeration for proper identification and expiration. A RN also verified the expired resident food should have been discarded per facility policy. CNAs stated nursing staff were responsible for labeling resident food and checking for expiration, and the Director of Dietary stated the nourishment refrigerators were checked twice daily and confirmed the expired milk cartons should not have remained in the refrigerator.
Trash Compactor Not Kept in Sanitary Condition
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed the facility’s kitchen trash compactor was not sealed, was not in good repair, and had foul odors, leaks, and accumulated liquid waste. On 04/07/2026 at 8:10 AM, the trash compactor was observed with a foul smell and various leaks along the side and bottom of the unit. At 8:16 AM, the head cook confirmed the compactor had a known leak and stated the area needed to be cleaned because of a safety hazard and the present foul odor. At 8:22 AM, the Maintenance Director verified the leak and confirmed the trash compactor needed to be replaced. On 04/08/2026 at 1:48 PM, the ADON confirmed the trash compactor was not sanitary, had a leak, and had an odor that would cause a pest concern. The facility policy titled Sanitization stated garbage disposal areas were to be free from odors and waste fats and maintained to prevent pests, and that garbage and refuse containers were to be cleaned and kept in good condition.
PPE Not Available in Laundry Room
Penalty
Summary
The facility failed to ensure appropriate PPE was available in the laundry room for staff handling soiled linens. During an inspection of the laundry room on 04/08/2026, gowns were not available for staff use. A laundry aide confirmed that gowns were not available in the laundry room and stated they would need to be obtained from another area of the facility, pointing toward the resident room areas and hallways. The facility had 18 confirmed, current resident infections listed on a Daily Overview Summary Report, including C. diff, wound infections, and cellulitis. The Infection Preventionist confirmed on 04/06/2026 that gowns were not available in the laundry room and acknowledged they should have been accessible to laundry staff to protect staff and prevent contamination from soiled or contaminated items. The DON later reported that gowns were expected to be easily accessible in the laundry room, and facility policies for Laundry and Bedding, Soiled and Departmental (Environmental Services) - Laundry and Linen stated that employees sorting or washing linen must wear gowns and gloves.
Lack of Defined Time Frame for Release of Medical Records
Penalty
Summary
The facility failed to ensure its Release of Information policy included a defined time frame for providing resident medical records upon request. A home health agency requested medical records for a resident on two occasions, with the first request made on 05/01/2025 and a second on 05/20/2025. The records were sent electronically on 05/20/2025 and 05/21/2025. The Medical Records Director stated that records would not be released without a request and that staff typically documented the portion of the record provided, but was unsure if other staff had documented the requests. There were no documented requests or phone calls from the home health agency regarding the resident, and fax cover sheets and written requests were only kept for 30 days. Review of the facility's Release of Information policy revealed it lacked documented time frames for processing such requests.
Failure to Provide Discharge Medication List and Education
Penalty
Summary
The facility failed to provide a copy of the discharge medication list and education about the medications to a resident upon discharge. The resident, who had been admitted with acute respiratory failure, chronic obstructive pulmonary disease, local infection of the skin and subcutaneous tissue, and sepsis, was discharged without documentation showing that a medication list or medication education was given. Interviews with facility staff, including a registered nurse, social services assistant, and the Director of Nursing (DON), confirmed that it was the nurse's responsibility to review and educate the resident on their discharge medications and instructions, and to ensure the resident understood and signed the discharge instructions. However, no such documentation was available for this resident. Review of the facility's policy titled Discharge Planning indicated that the nursing department was responsible for assessing and coordinating health and medical education needs, and that the discharge packet should include a medication list and prescriptions. The former DON also confirmed that there should have been documentation of medications provided and education given to the resident at discharge. The lack of documentation and education regarding discharge medications constituted a deficiency in the facility's discharge process for this resident.
Failure to Enforce Non-Smoking Policy and Remove Smoking Materials
Penalty
Summary
The facility failed to ensure that interventions were implemented to identify hazards and risks associated with smoking for three residents. Resident 14 was found with a lighter and cigarettes in their room, and attempted to dispose of a used cigarette in a trash can containing combustible materials. Despite being informed of the non-smoking policy, Resident 14 refused to relinquish the smoking materials. The resident had a history of schizophrenia, depression, and suicidal ideations, and was moderately impaired with a BIMS score of 12. The Comprehensive Care Plan did not include a smoking care plan for Resident 14. Resident 34, who was a documented smoker with an oxygen concentrator in their room, was also involved. The resident was observed to have smoked in the courtyard and main entrance with other residents. Despite the potential fire hazard posed by the oxygen concentrator, there was no documented evidence of a smoking care plan for Resident 34. The resident had a history of psychoactive substance dependence, alcohol dependence, and nicotine dependence, and was moderately impaired with a BIMS score of 12. Resident 116 was found with a lighter in their possession and admitted to smoking with Resident 14. The facility had recently put up non-smoking signs and instructed residents to smoke off property, but Resident 116 indicated they were not informed of the non-smoking policy upon admission. The resident was cognitively intact with a BIMS score of 14 and had a history of depression and opioid dependence. The facility's failure to enforce the non-smoking policy and remove smoking materials from residents posed a significant fire hazard, especially with the presence of residents on oxygen.
Improper Food Labeling and Storage in Facility
Penalty
Summary
The facility failed to ensure that opened items in the refrigerator and freezer were properly labeled and discarded upon expiration, as per policy. During an inspection, a surveyor, along with the Director of Dietary Services, observed several items in the walk-in refrigerator and freezer that were not labeled or dated correctly. These included a large bin of chopped onions with an outdated label, a half-cut large tomato wrapped in plastic without a label, and a large plastic bin of canned fruits that was unlabeled. Additionally, an undated chocolate cream pie in the freezer had been opened and cut in half without proper labeling. The Director of Dietary Services confirmed these observations and acknowledged that the dietary staff were responsible for ensuring that partially used or opened items were labeled, dated, and discarded in a timely manner. The facility's guidelines and policies required that all foods stored in the refrigerator or freezer be covered, labeled, and dated, with specific timelines for discarding opened items.
Failure to Implement Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans for several residents within 48 hours of admission, as required by their policy. Four residents who were identified as smokers did not have smoking care plans in place, despite their tobacco use being documented in their medical records. The Director of Nursing (DON) acknowledged that smoking care plans should have been developed, even though the facility had a smoke-free policy. This lack of care planning was confirmed through interviews with the residents and the DON. Two residents with communication deficits due to language barriers also lacked appropriate baseline care plans. One resident, whose primary language was Mandarin, did not have a communication board or any documented interventions to address the language barrier. Another resident, who spoke only Spanish, was unable to communicate effectively with staff who spoke only English. The DON confirmed that care plans addressing these communication barriers were not developed, which hindered effective communication with these residents. Additionally, a resident with a peripheral intravenous (IV) catheter did not have a care plan in place for the IV access. The resident was observed with an IV access that was not properly documented or managed, increasing the risk of infection. The Infection Preventionist and the DON acknowledged the oversight, noting that a care plan should have been developed to manage the IV access, including regular dressing changes and physician orders. This deficiency in care planning was recognized as a risk for potential complications due to infections.
Failure to Develop Smoking Care Plans for Tobacco-Using Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents who were identified as tobacco users. Despite the residents' tobacco use being documented in their Minimum Data Set (MDS) assessments, the facility did not create smoking care plans that included focus, goals, and interventions. This oversight was noted for three residents, each with significant medical histories, including schizophrenia, depression, psychoactive substance dependence, and opioid dependence. The absence of these care plans was attributed to the facility's policy of being non-smoking, which led to the assumption that smoking care plans were unnecessary. The MDS Coordinator and the Director of Nursing (DON) acknowledged the lack of smoking care plans, despite the MDS indicating current tobacco use. The facility's policy on comprehensive, person-centered care plans requires measurable objectives and timeframes, services to maintain the resident's well-being, and reflection of recognized standards of practice. However, the facility did not adhere to this policy for the residents in question, as no smoking care plans were developed, potentially depriving them of necessary interventions.
Delayed Response to Call Lights in Facility
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner, affecting one sampled resident and two unsampled residents. On February 26, 2025, a call light in a resident's room was activated at 8:38 AM, but it was not answered until 9:03 AM, despite staff being present in the vicinity. The resident had activated the call light to request an adjustment to the room temperature. A CNA eventually responded, acknowledging that call lights were everyone's responsibility, but it seemed that only CNAs were expected to answer them. An LPN at the nursing station noted that the call light system had been malfunctioning since February 24, 2025, causing a constant alarm sound that masked the real call light alarm, and it was unclear if the issue had been reported to maintenance. Another incident involved a resident, identified as Resident 17, who was observed in distress at the nursing station on the 100 hall. The resident, who had a history of gout, type 2 diabetes mellitus with hyperglycemia, and spondylosis, reported severe pain and had activated the call light over an hour earlier to request pain medication. Despite the presence of four staff members at the nursing station, the resident's request was not acknowledged until a nurse approached and administered pain medication. The nurse stated that no one had reported the resident's pain to them. Additionally, on March 6, 2025, a resident in a room across from the 200-hall nursing station was heard emitting loud cries for help, which were ignored by passing staff members. The cries continued for approximately 15 minutes before a staff member attended to the resident. A Resident Council Log from January 15, 2025, documented a resident's complaint about delayed responses to call lights, and a subsequent meeting response indicated that education was provided to staff on the importance of timely call light responses. The Director of Nursing and the Administrator acknowledged ongoing Quality Assurance and Performance Improvement (QAPI) projects related to call light response times.
Failure to Follow Physician's Order for Foley Catheter Size
Penalty
Summary
The facility failed to ensure proper assessment and documentation of a Foley catheter for a resident, leading to a deficiency. The resident, who was admitted with acute kidney failure and obstructive uropathy, had a Foley catheter in place that was not in accordance with the physician's order. The physician had ordered a 14 French catheter with a 10 ml water balloon, but the resident had a 16 French catheter instead. This discrepancy was confirmed by an LPN and the Assistant Director of Nursing (ADON), who noted that the catheter size should match the physician's order to prevent potential trauma or leakage. The facility's documentation consistently indicated the use of a 14 French catheter, despite the actual use of a 16 French catheter. The ADON and the physician both emphasized the importance of following the physician's order for catheter size to avoid complications. The facility's policy on catheter care, revised in August 2022, required accurate documentation of catheter assessments, including urine characteristics, to prevent complications such as urinary tract infections. However, the failure to adhere to the physician's order and accurately document the catheter size in the medical record led to the identified deficiency.
Failure to Conduct Nutritional Assessment and Address Severe Weight Loss
Penalty
Summary
The facility failed to conduct an impaired nutrition assessment or a comprehensive nutritional assessment for a resident upon admission, which led to a lack of interventions for severe weight loss. The resident, who was cognitively intact, experienced a significant weight loss of 35.70 pounds, equating to a 12.80% decrease, over a period from early July to early August. Despite the facility's policy requiring a nutritional assessment upon admission, there was no documented evidence of such an assessment or a nutritional care plan in the resident's comprehensive care plan. The Registered Dietician confirmed the absence of a nutritional assessment and interventions for the resident's weight loss, which should have prompted a dietary consultation. The Director of Nursing and the Director of Staff Development acknowledged the lack of documentation regarding a change of condition or dietary consultation. The facility's policies on nutritional assessment and weight intervention were not followed, as there was no evaluation or intervention for the resident's undesirable weight change, which was necessary to address the resident's nutritional needs and potential causes of weight loss.
Failure to Follow Tube Feeding Orders and Monitor Nutritional Intake
Penalty
Summary
The facility failed to ensure that the tube feeding order for a resident with dysphagia and a gastrostomy was followed, leading to a significant discrepancy in the total dose volume consumed. The resident, who had a history of aspiration pneumonia and was at risk for malnutrition, was observed with the enteral pump turned off during the day, despite orders for nocturnal feeding. The Registered Dietitian and Licensed Practical Nurse confirmed that the total dose delivered over 72 hours was significantly less than ordered, resulting in a shortage of 1269 mL and 1800 calories, which was significant for the resident's wound healing and recovery. The Registered Nurse and Director of Nursing acknowledged that the tube feeding should have been monitored to ensure completion, but there was no documentation of the total dose consumed. The facility's policy required adequate nutritional support through enteral nutrition, but the staff failed to monitor and document the resident's nutritional intake as ordered. The Director of Nursing attributed the resident's significant weight loss to multiple factors, including a history of Clostridium difficile and family interference, but confirmed that the actual dose of tube feeding consumed was not documented.
Failure to Obtain Physician's Orders and Document IV Access
Penalty
Summary
The facility failed to obtain a physician's order for the use of intravenous (IV) access or heplock for two residents, Resident 104 and Resident 325, and did not properly assess, monitor, or document the IV sites. For Resident 104, who was admitted with diagnoses including anemia and malignant neoplasm of the rectum, an IV heplock was observed to be 10 days old, soiled, and not documented in the medical record until 10 days after insertion. The charge nurse and Assistant Director of Nursing confirmed the lack of documentation and the failure to change the IV heplock every two to three days as required to prevent infection. Resident 325, admitted with diagnoses including bipolar disorder and acute respiratory failure, had a peripheral IV access on the left hand that was covered with an adhesive transparent dressing dated 11 days prior to observation. The resident's medical record lacked documentation of whether the IV access was present upon admission or inserted afterward, and there were no physician orders for placement, monitoring, or discontinuation. The IV nurse confirmed the IV access was used only once for a Banana bag administration and had not been monitored or assessed since. The facility's policies on Peripheral IV Catheter Insertion and Removal required a provider's order and documentation of the procedure, including the condition of the IV site and the resident's response. The Director of Nursing acknowledged the lack of documentation and orders, which increased the risk of infection and complications for the residents. The Infection Preventionist also noted the failure to identify and assess IV access upon admission and the need for regular dressing changes to prevent infection.
Inadequate Pain Management and Documentation for Two Residents
Penalty
Summary
The facility failed to consistently assess, manage, and document pain management for two residents, leading to inadequate pain relief. Resident 273, who had undergone back surgery and was experiencing severe pain, reported that requests for pain medication were ignored, and the pain medication provided was insufficient. The facility's policy required pain to be assessed every 30-60 minutes after onset, but there was no documented evidence of such assessments or reassessments in the electronic Medication Administration Record (eMAR). Staff interviews confirmed that the pain assessments were not consistently conducted or documented, and the system-generated prompts for follow-up were not adhered to. Resident 17, who had a history of gout, diabetes, and spondylosis, was observed in visible distress and reported severe pain to staff at the nursing station. Despite activating the call light over an hour prior, the resident's pain was not addressed until later, and the administration of pain medication was not documented in the eMAR. The facility's policy required documentation of medication administration and reassessment of pain within 30-60 minutes, but these steps were not followed, as confirmed by the Director of Nursing and other staff members. The lack of consistent pain assessment and documentation for both residents highlights a failure to adhere to the facility's pain management policies. This deficiency resulted in unrelieved pain and discomfort for the residents, as their pain levels were not adequately monitored or managed according to the established protocols. The staff's failure to document and reassess pain management interventions contributed to the inadequate care provided to the residents.
Medication Error Rate Exceeds 5% Due to Dosage and Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during a medication pass, resulting in an 8% error rate. This was observed through 25 medication administration opportunities, where two errors were identified. One error involved a resident who was prescribed 1 mg of Folic Acid daily but was administered only 400 mcg. The LPN responsible for the administration acknowledged the mistake, noting that there were two bottles of Folic Acid available and the dosage should have been double-checked. The pharmacist confirmed that the correct dosage was not administered, and the Director of Nursing emphasized the importance of adhering to the resident's rights, including the correct dosage. Another error involved a resident with a prescription for Cardizem 120 mg to be administered daily for hypertension, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110. The LPN withheld the medication when the resident's SBP was exactly 110, misunderstanding the parameter. The LPN later confirmed that the medication should have been administered, as the SBP was not below the threshold. The Director of Nursing reiterated the expectation for licensed nurses to follow medication administration parameters and consult the physician if there is any doubt.
Failure to Maintain Functional Call Light System
Penalty
Summary
The facility failed to maintain a functioning call light system in the 200 hall, which compromised the safety and responsiveness to residents' needs. On multiple occasions, the call light in a resident's room was activated but not promptly answered, despite staff being present in the vicinity. The resident expressed discomfort due to the room temperature and had to wait 25 minutes before a CNA responded. The CNA indicated that there was a misunderstanding among staff regarding the responsibility for answering call lights. The call light system had been malfunctioning since 02/24/2025, producing a constant alarm sound that masked the actual call light alerts. This malfunction was not reported in the maintenance log, and the LPN at the nursing station confirmed the issue was not visible from their location. The system's failure was discovered by maintenance staff while addressing an unrelated issue. Additionally, the call light activators in the bathrooms of two other rooms were found to be non-functional, but these issues were not documented in the maintenance log. The facility lacked a specific policy for the call light system's requirements or maintenance, as confirmed by the DON. The Administrator was unaware of the call light system issue until informed during the survey. Staff had been attempting to reset the system by unplugging it, which was ineffective. The absence of a documented policy and the failure to report and address the malfunctioning system contributed to the deficiency, leaving residents at risk of delayed assistance.
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What surveyors actually found near you
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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 Las Vegas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spanish Hills Wellness Suites | 2.3 mi | ★★★★★ | 26 | 0 |
| Sandstone Spring Valley | 2.9 mi | ★★★★★ | 42 | 0 |
| Advanced Health Care Of Las Vegas | 3.9 mi | ★★★★★ | 10 | 0 |
| Las Ventanas Retirement Comm Snf | 6.1 mi | ★★★★★ | 0 | 0 |
| The Heights Of Summerlin, Llc | 6.2 mi | ★★★★★ | 21 | 0 |
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