The Canyons Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of four sampled residents (Residents 1 and 2), when Resident 1's call light was located on the floor, and Resident 2's call light was wrapped around the bed rail. In both instances, the call lights were out of reach of Resident 1 and Resident 2.These failures had the potential to delay Residents 1 and 2's ability to request assistance when needed, increasing the risk of unmet care needs, and possible injury.Findings: A review of Resident 1's face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure (a long-term condition where the lungs cannot properly move oxygen into the blood or remove carbon dioxide), and Klebsiella Pneumoniae (a type of bacterium that can cause severe, hard-to-treat infections if it spreads to lungs or blood).During a concurrent observation and interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure their Bed-Holds (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) and Returns policy and procedure was implemented for one of four sampled residents (Resident 1) when Resident 1's responsible party (Resident 1's daughter) was not provided any verbal or written information regarding Resident 1's right to exercise the bed hold provision (legal requirement, often lasting 7 days, that allows nursing home or skilled nursing facility (SNF) residents to reserve their specific bed while temporarily hospitalized ) when he was transferred to the general acute care hospital (GACH) on January 4, 2026.This failure resulted in Resident 1 and Resident 1's representative not being able to exercise their right for the bed hold provision.Findings:A review of Resident's 1 admission Record (a document containing clinical and demographic information data) indicated Resident 1 was initially…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that call light was within reach for two of four sample residents (Resident 1 and 2) reviewed, when Resident 1's call light was observed wrapped around the left bed rail with the cord hanging down towards the floor, while the bedside table was placed against the left bed rail, obstructing access to the call light. Resident 2's call light was observed clipped to the top portion of the bed with the cord oriented away from Resident 2, placing it out of Resident 2's reach.This failure had the potential to delay Resident 1 and 2's ability to request assistance when needed, increasing the risk of unmet care needs, and exacerbating the confusion of Resident 1 and 2, leading to possible Injury.During a review of Resident 1's face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease stage 3B (moderate to severe kidney function…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that respiratory therapists were available for 41 residents when there was no respiratory therapist on duty for approximately seven (7) hours during the night shift of October 12, 2025.This failure had the potential to place clinically compromised residents' health and safety at risk by not having a respiratory therapist available to provide appropriate care when necessary.Findings:During an interview on 10/14/2025, at 3:00 PM, with one of the residents (Resident 1), Resident 1 stated, two nights ago, there was no RT (Respiratory Therapist) at all. The nurses do not know how to operate the machine; I just stayed off the machine. I was suctioned before the RT left.During an interview on 10/14/2025, at 3:50 PM, with Respiratory Therapist (RT 1), RT 1 stated, I came early Monday [10/13/2025] at 5:00 AM, I clocked in before 5:00 AM, there was no RT on duty. RT 1 indicated that the scheduled RT called off, and another RT, who lacks work permit, did not report to work. To address the situation, an RT from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure appropriate dialysis (the process of removing excess water and cleaning the blood) treatment was acquired for one of three residents (Resident 1) for 2 days.This failure resulted in a clinically compromised resident Resident 1 not receiving dialysis as ordered by the physician and was sent out to acute hospital for treatment and placing health and safety at risk. Findings:During review of Residents 1's admission Record (general demographics information), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which include End Stage Renal Disease (kidneys have severe damage) dependent on Renal Dialysis, acute respiratory failure (fluid prevents lungs filling with air), hypertension (high blood pressure).During a record review on October 23, 2025, at 11:30AM, Resident 1's medical records, reviewed and verified the following:1. History and Physical dated October 22, 2025: Patient is not able to make own…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow their policy in providing Activities of Daily Living (ADLS) when showers/bed bath were not provide as scheduled for 17 of 25 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12,13,14,15,16, and 17).This failure had the potential to result in skin irritation, odor, and decreased quality of life for the residents.Findings:During a concurrent interview and record review of the Shower Schedule Station 2 with the Certified Nursing Assistant (CNA 2), on July 9, 2025, at 2:36 PM, CNA 2 stated they have residents who complained about not receiving showers on Saturdays. Review of the Shower Schedule Station 2 document indicated the following schedule for Wednesday's and Saturday's:a. Hallway 1, AM shift: 201B, 202B, 207B, 208B, 209A, 210Ab. Hallway 2, AM shift: 215A, 216A, 220B, 222A, 225Cc. Hallway 3, AM shift: 227B, 228B, 233A, 236Ad. Hallway 1, PM shift: 203A, 209B, 211C, 212Ae. Hallway 2, PM shift: 215B, 214A, 218Bf. Hallway 3, PM shift:228A, 230B, 236BDuring a review of the electronic medical record for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the Certified Nursing Assistant (CNA) performed hand hygiene after doffing (removing) Personal Protective Equipment (PPE) upon leaving the isolation (to keep patients with contagious diseases separate from others) room for two of 25 (Resident 18 and 19).This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasites) to other residents and staff in the facility.Findings:During a concurrent observation and interview on July 08, 2025, at 1:54 PM, with the Certified Nursing Assistant (CNA 3), CNA 3 was observed to enter the isolation room for Resident 18 wearing gloves and isolation gown. CNA 3 exited the room and doffed (removed) her (PPE). CNA 3 did not perform hand hygiene after doffing her PPE. CNA 3 stated she did not touch the resident or anything in the room, that is why she did not do hand hygiene.During a review of Resident 18's clinical record, the isolation list indicated Resident 18 was placed on contact precautions on July 08, 2025, due to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to perform timely maintenance on the ventilators (a breathing machine or breathing device that helps a resident breath when they cannot do it on their own) for two (2) of five (5) sampled residents (Residents 1 & 2). This failure has the potential to cause malfunctions of the ventilators, which may place the health of clinically compromised Residents 1 and 2 at risk. Findings: During an observation on 5/22/2025, at 12:43 p.m. in the Subacute Unit, with the respiratory therapist (RT 1) and the Assistant Director of Nursing (ADON), it was noted that the two ventilators currently in use for Resident 1 and Resident 2 were overdue for service maintenance. The maintenance sticker observed for both ventilators indicated the following: a. For Resident 1 - preventative maintenance was due on June 17, 2023. b. For Resident 2 - preventative maintenance was due on September 20, 2024. The ADON and RT 1 acknowledged that preventive maintenance for both ventilators is already past due. During a concurrent interview and review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow its Activities of Daily Living ADLs policy and procedure for 3 of 3 sampled Residents (Resident ' s 1,2 and 3) when: Resident ' s 1, 2 and 3 were left soiled and wet on observation April 30, 2025. This failure had the potential to cause (Resident 1,2, and 3) health and safety to be at risk for skin breakdown when their care needs were not met. Findings: 1. During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: encephalopathy (brain disease altering function, causes: infection tumor or stroke), respiratory failure, tracheostomy status (trach tube assisting with breathing). Hypertension (high blood pressure). During a concurrent observation and interview on April 30, 2025, at 11:30AM, with License Vocational Nurse (LVN1) at bedside assisting during observation. Resident 1 brief is completely drenching wet, linen sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure an admission Minimum Data Set (MDS) assessment was completed no more than 13 days after the admission date for 1 (Resident #333) of 27 sampled residents for whom MDS assessments were reviewed. Findings included: On 03/06/2025 at 12:50 PM, the Administrator stated the facility did not have a policy that addressed MDS assessments, but the facility went by the RAI Manual. The CMS Long-Term Care Facility RAI 3.0 3.0 User's Manual, version 1.19.1, October 2024, revealed section 5.2 Timeliness Criteria, specified, - For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600). An admission Record indicated the facility admitted Resident #333 on 02/11/2025. Resident #333's admission MDS, with an Assessment Reference Date (ARD) of 02/18/2025, revealed A1600.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment accurately reflected the location to which a resident was discharged for 1 (Resident #128) of 27 sampled residents for whom MDS assessments were reviewed. Findings included: On 03/06/2025 at 12:50 PM, the Administrator stated the facility did not have a policy that addressed MDS assessments, but the facility went by the RAI Manual. The CMS Long-Term Care Facility RAI 3.0 3.0 User's Manual, version 1.19.1, October 2024, revealed section A2105: Discharge Status specified, Code 09, Hospice (home/non-institutional): if the resident was discharged to a community-based program for terminally ill persons. An admission Record indicated the facility admitted Resident #128 on 11/19/2024. According to the admission Record, the resident had a medical history that included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #104) of 6 sampled residents reviewed for unnecessary medications was monitored for the presence of adverse drug reactions or other side effects related to the use of a prescribed antipsychotic medication. Findings included: A facility policy titled, Antipsychotic Medication Use, revised in 01/2020, indicated, 9. Nursing staff shall monitor for and report adverse consequences of antipsychotic medications to the Attending Physician. Resident #104's admission Record indicated the facility admitted the resident on 09/22/2024. According to the admission Record, the resident had a medical history that included a diagnosis of depression. Resident #104's Order Summary Report contained an order dated 12/26/2024 for Zyprexa Zydis (olanzapine orally disintegrating tablets, an atypical antipsychotic medication) 5 milligrams (mg), one-half tablet by mouth one time a day for hyperactive delirium, end of life. The Order Summary Report did not include orders to monitor for adverse drug…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure nursing staff cleaned and disinfected supplies between resident uses for 2 (Resident #72 and Resident #38) of 7 residents observed during medication administration observations. Findings included: A facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, revealed, 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care, including, c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers. (2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). d. Reusable items are cleaned and disinfected or sterilized between residents (e.g. [exempli gratia, for example], stethoscopes, durable medication equipment). The policy specified, 3.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow its Activities of Daily Living ADLs policy and procedure for 3 of 4 sampled Residents (Resident's 1,2 and 3) when: 1. Resident 1 used call light to get staff attention for help, waiting over an hour. 2. Resident 2 used call light to get assistance, then is turned off by staff failing to return or returning after an hour wait. 3. Resident 3 used call light along with roommates to help get assistance, staff states I'm not the assigned staff will look for assigned staff, this prolonged already long wait times. This failure had the potential to cause (Resident 1,2, and 3) health and safety to be at risk for skin break down when their care needs were not met. Findings: During interview and Records Reviewed with (Resident 1,2, and 3) indicates as followed: 1. During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and homelike environment, when the shower room used by two of three sample residents (Resident 1 and 2) had uneven flooring, fractured tiles, and permanent residue on the wall. This failure had the potential to affect the health and wellness of Resident 1 and 2. Findings: During a telephone interview on October 21, 2024, at 8:45 AM, with Resident 1, Resident 1 stated shower room was dirty there was gloves on the floor, shower stall wasn ' t working there was no hot water at that time, the floor has mold that need to be scrubbed more. During a review of Resident 1 ' s clinical records, the admission Record (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included Osteomyelitis (bone infection), type 2 diabetes (Type 2 DM – a chronic disease that occurs when the body doesn ' t produce enough insulin or doesn ' t used insulin properly resulting in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to adhere to its safety and supervision of resident ' s policy when one of the four sampled residents (Resident 1) was left unattended during patient care. This failure had the potential to put a clinically compromised resident (Resident 1) at risk for serious injury, resulting in Resident 1 falling and requiring transfer to an acute general hospital for evaluation and treatment. Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE] with a diagnosis that included persistent vegetative state (someone with brain damage appears to be awake but does not respond to their surroundings or perform purposeful actions). During an interview on 9/24/2024 at 2:07 p.m. with Licensed Vocational Nurse (LVN)1, LVN 1 stated the certified nursing assistant (CNA) was in the process of changing Resident 1. The CNA went to gather supplies, and upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for all three sampled residents (Residents 1, 2, and 3). This failure has the potential to jeopardize the health and safety of three clinically compromised Residents (Residents 1, 2, and 3) when their requests for assistance with activities of daily living were not responded to promptly. Findings: During an interview on October 11, 2024, at 9:30 AM, with Resident 1, Resident 1 in bed, is alert and oriented. Resident 1 stated it took a while for the staff to answer the call light, at night it takes more than 20 minutes. During review of Resident 1 ' s admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure 1 of 3 sampled residents (Resident 1), was provided proper wound care treatments and assessment. This failure placed a clinically compromised Resident (Resident 1) health and safety at risk. When skin integrity was not being treated and assessed by nursing staff that resulted in infection and hospital stay. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: acute kidney failure (kidneys lose ability to remove waste), heart failure (heart doesn't pump blood as well), osteomyelitis to left ankle and foot (inflammation of bone caused by infection), diabetes type II (body does not produce enough insulin, or resist insulin), hypertension (high blood pressure). During a concurrent interview and record review of Resident 1's Medical Record with the Assistant Director of Nursing (ADON) reviewed and verified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights were answered in a timely manner for two out of four sampled residents (Residents 1 and 2). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Resident 1 & Resident 2) when their requests for assistance with activities of daily living were not responded to promptly. Findings: During the review of Resident 1's admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included unspecified hyperlipidemia (increase levels of lipids - like cholesterol [waxy substance found in the blood] with high cholesterol increases the chance of heart problem). During an interview and observation with Resident 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to follow its policy and procedure for prevention of pressure ulcers/injuries when one of four sampled residents (Resident 1) was not repositioned in a timely manner. This failure resulted in the development of pressure ulcer of clinically compromised resident (Resident 1). Findings: During the review of Resident 1's admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included unspecified hyperlipidemia (increase levels of lipids - like cholesterol [waxy substance found in the blood] with high cholesterol increases the chance of heart problem). During an interview and observation with Resident 1 on July 3, 2024, at 11:20 AM, the resident stated that staff responses to call lights are typically delayed, taking an hour or two during the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow Its policy and procedure to provide Activities of Daily Living Services (ADLS) and ensure call lights are answered in timely manner for two of three sampled residents. (Resident's 2 and 3). This failure had the potential to place clinically compromised Residents (Resident 2 and 3) health and safety at risk. When residents were left soiled, and their hygiene needs were not met. Findings: During a review of Resident 2's (R2) admission Record (general demographics), the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses to include: cardiac arrest (loss of heart function), chronic respiratory failure (lungs cannot get enough oxygen, dependent on ventilator, machine to provided oxygen), type2 diabetes (body doesn't produce enough insulin, or resist insulin), anoxic brain damage (complete lack of oxygen to the brain). During a concurrent observation and interview on March 28, 2024, with Resident 2's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow its policy and procedure to provide activities of daily living services (ADLS) and ensure two of three residents (Resident 1 and Resident 2) received care with changing when needed. This failure had the potential to place two clinically compromised Residents (Resident 1 and 2) health and safety at risk. When residents were left soiled, and their hygiene needs were not met. Findings: During a review of Resident 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which include acute cholecystitis (a condition with redness and swelling of the small organ under the liver), lack of coordination (a condition which causes jerky movements), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), osteoarthritis right knee (a condition in which the joint break down overtime) and, hypertension (high…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure their abuse policy and procedure was implemented, when a Licensed Vocational Nurse (LVN 2) and a Registered Nurse (RN) did not report an allegation of rape to the Administrator and Director of Nursing (DON) immediately, for one of three sampled residents (Resident 1), on December 24, 2023. This failure had the potential for Resident 1 to experience psychosocial harm. Findings: During a review of Resident 1 ' s Face Sheet (contains demographic data), the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included, chronic respiratory failure (shortness of breath), encounter for attention to tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening from outside the neck), quadriplegia (paralysis that affects limbs and body from the neck down), major depressive disorder (a serious medical illness that negatively affects how you feel, the way you think and how you…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that an injury of unknown origin was promptly reported to the California Department of Public Health (CDPH) in accordance with the facility's policy, for one of three residents (Resident 1). This failure had the potential for an injury of unknown origin to go uninvestigated and unreported thereby increasing the chances of harm to Resident 1. Finding: An abbreviated survey was conducted on November 22, 2023, at 2:50 PM to investigate a complaint related to accidents. A review of Resident 1's face sheet (contains demographic information) indicated, Resident 1 was admitted to the facility on [DATE], with diagnosis which included: Encephalopathy (disturbance in the way the brain functions), Alzheimer's disease (gradual decline in memory, thinking, behavior and social skills) and muscle weakness. During a review of the clinical record for Resident 1, the admission Assessment titled, Wandering Risk Scale dated November 12, 2023, indicated Resident 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent an elopement (unsupervised wandering that leads to the resident leaving the facility) by Resident 1 when he left the facility unnoticed and was found unsupervised in the parking lot. This failure resulted in a mentally compromised resident (Resident 1) sustaining a fall with injuries and placed this residents' safety at risk. Findings: An abbreviated survey was conducted on November 22, 2023, at 2:50 PM to investigate a complaint related to accidents. A review of Resident 1's face sheet (contains demographic information) indicated, Resident 1 was admitted to the facility on [DATE], with diagnosis which included: Encephalopathy (disturbance in the way the brain functions), Alzheimer's disease (gradual decline in memory, thinking, behavior and social skills) and muscle weakness. During a review of the clinical record for Resident 1, the admission Assessment titled, Wandering Risk Scale dated November 12, 2023, indicated Resident 1 was a high risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update a comprehensive care plan for one of three Residents (Resident 1). This failure contributed to the decline and development of Resident 1 ' s pressure ulcers. Findings: An abbreviated survey was conducted on August 2, 2023, at 2:20 PM to investigate a complaint regarding Quality of Care. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: Dysphagia and central cord syndrome of cervical spine cord sequela (injury to the spinal cord causing weakness in the arms and legs.) During a review of the clinical record for Resident 1, the change in condition note, dated May 9, 2023, indicated wound to the sacrum, deep tissue injury, 3 cm (centimeters, unit of measure) by 3 cm with scant amount of drainage noted. During a review of the clinical record for Resident 1, the Care Plans, undated indicated, Resident 1 did have an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based an interview, and record review, the facility failed to ensure a one of three residents (Resident 1) did not develop a pressure ulcer when staff did not reposition and turn Resident 1 frequently or every two hours as per their policy. This failure contributed to the development of a pressure ulcer to Resident 1 ' s sacrum (bone located on the bottom of the spine). Findings: An abbreviated survey was conducted on August 2, 2023, at 2:20 PM to investigate a complaint regarding Quality of Care. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: Dysphagia and central cord syndrome of cervical spine cord sequela (injury to the spinal cord causing weakness in the arms and legs.) During a review of the clinical record for Resident 1, the admission assessment dated [DATE], indicated Resident 1 was admitted on [DATE], with redness to the cervical neck incision, redness to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow policy and procedure to ensure call lights were answered in timely manner to provide care and services for three of three sampled residents (Resident 1,2, 3). This failure had the potential to place a clinically compromised Residents (Resident 1,2, 3) health and safety at risk. When residents were left soiled, and their activities of daily living were not met in timely manner. Findings: During review of Residents 1's (R1) admission Record (general demographics), the document indicated R1 was admitted to the facility on [DATE], with diagnoses to include hemiplegia and hemiparesis (weakness/paralysis on one side of body), myasthenia Gravis ( a condition causing abnormal weakness of certain muscles), Chronic Respiratory Failure ( difficult to breath ), tracheostomy dependence ( people who have breathing problems with tracheostomy and may also need breathing support from a mechanical ventilator ). During interview with R1 on July 25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen environment when: 1. The walk-in freezer that provided storage of food for 83 out of 120 residents, had a red colored dry spillage and crumbs under where the meat and chicken trays were stored. This had the potential for microorganism (small organisms which have the potential to cause disease) growth and to attract pests. 2. The floor under the oven and stove had food crumbs, trash and grime, and there were streaks of residue and grime on the sides of the oven and stove. This had the potential to promote bacterial growth within this area as well as attract microorganisms. The facility failures to ensure a safe and sanitary food preparation could result in the increased risk of resident harm related to disease-causing microorganisms contaminating the residents' food which could cause food-borne illness to a population of immunocompromised (residents who can easily get sick due to their inability to fight infection) residents who received food from the kitchen. Findings: 1. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect when one of three sampled residents (Resident 420) pressed the call light for help because she felt like she could not breathe, and waited 20 minutes for assistance, despite multiple staff members passing her room as the resident loudly pleaded for help. This failure had the potential to cause Resident 420's needs go unmet, resulting in fear, anxiety, and frustration. Findings: During an observation on April 6, 2023, at 5:42 AM, the call light was on outside of Resident 420's room. Resident 420 was heard saying she could not breathe. A staff member walked past the resident's room and did not acknowledge the call light was on or the resident stating she could not breathe. Another staff, Licensed Vocational Nurse (LVN 1) also walked past the resident's room without acknowledging the call light as the resident repeatedly stated she could not breathe. During an observation on April 6,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents could exercise their rights within the facility when one of three sampled residetns (Resident 83) requested for her foley catheter (a flexible tube used to drain urine) to be discontinued but was not carried out as ordered by the attending physician. This failure had the potential for a negative psychosocial outcome for one of three sampled residents (Resident 83) related to her right to make decisions about her care and treatment. Findings: During a concurrent observation and interview on April 4, 2023, at 9:47 AM, Resident 83 was observed with an in-dwelling foley catheter. Resident 83 stated she told her doctor that she wanted her foley catheter be discontinued. She further stated, she did not have a foley catheter when she was at home. During record review of Resident 73's face sheet (a document containing basic information, demographics, and diagnoses), indicated Resident 73 was admitted to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess and document resident's current health status for the use of an anticoagulant (blood thinner) during Minimum Data Set (MDS, (a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status), assessment. This failure had the potential for care and services to remain unmet for one (Resident 10) of six sampled residents. Findings: During a concurrent observation and interview on April 4, 2023, at 11:09 AM, Resident 10 was observed with skin discoloration on her right knee due to a fall that occurred at her home. Resident 10 also stated she currently takes Pradaxa as anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart, also called blood thinner.) A review of Resident 10's face sheet (a document containing resident's basic information and diagnoses) indicated Resident 10 was admitted on [DATE], with a diagnosis that included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide oversight and ensure that only Dialysis (a life sustaining procedure of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions naturally) Registered Nurses were allowed to access residents' central venous catheters (CVC), (CVC- a plastic flexible tube that's located in the neck, upper chest, or groin. The CVC is connected to the bloodlines during dialysis, allowing for the transfer of blood to and from the body to the dialysis machine and back) during the provision of resident's dialysis care, according to professional standards of practices when: 1) Dialysis Caregiver 1 (DC 1) accessed (to initiate use) Resident 216's CVC 2) Dialysis Caregiver 2 (DC 2) accessed Resident 220's CVC 3) Dialysis Caregiver 3 (DC 3) accessed Resident 6's CVC These failures had the potential for resident harm and/or death, the risk of the residents acquiring blood borne infections (infection caused…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were safely prepared for six out of six residents (Resident 418, 115, 416, 417, 420, and 69) when one Licensed Vocation Nurse (LVN 1) prepared medications for the six residents at the same time and more than three hours in advance of when the medications were ordered for administration. This failure had the potential for these vulnerable residents to receive the wrong medications, which could lead to adverse health outcomes and/or death. Findings: During an observation and interview on April 6, 2023, at 5:44 AM, with LVN 1, outside of Resident 417's room, six clear medication cups were lined up at the back of LVN 1's medication cart (used to transport resident medications). The medication cups were labeled with resident room numbers and in the medication cups were various pills, an alcohol wipe, a lancet (sharp needle used to obtain blood for testing glucose), and test strips (small piece of plastic used to measure blood sugar) for the glucometer (medical device used to monitor glucose in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure resident medications were secured, when one (med cart 1) of four medication carts (used to transport resident medications) were found unlocked and unattended by a licensed nurse, with the keys to unlock the narcotics (prescription pain medications) drawer placed on top of the medication cart. This failure had the potential to compromise the security of the medications and potentially allow unauthorized staff and residents to access these medications. Findings: During an observation on April 6, 2023, at 5:30 AM, a medication cart 1 was unlocked and unattended. On top of the medication cart 1 was a yellow coil wristband with a key ring and three keys attached to it, and one key was labeled NARC. During a concurrent observation and interview on April 6, 2023, at 5:35 AM, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 opened a drawer in the medication cart without using a key to unlock it. The medication drawer stored bubble packs (medications dispensed in sealed compartments) of resident medications. LVN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.