Canyon Creek Post-Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to safely transfer one of three sampled residents (Resident 1) from wheelchair to bed using a Hoyer lift (a mechanical device used to lift and transfer residents with limited mobility), when one of loops/straps of the sling (a supportive fabric, shaped like a hammock which holds the residents. Loops of the sling are attached to the bars of the Hoyer lift) broke, causing Resident 1 to land directly onto the floor. This failure resulted in Resident 1 hitting his left leg onto the bottom bar (base) of Hoyer lift, sustaining a laceration (deep cut in the skin) on left shin, requiring transfer to an acute care hospital for staples (metal or plastic clips applied to close a tear in the skin) and Resident 1 feeling lack of confidence in facility's capabilities. [...]

Inspectors wroteBased on observation, interview and record review, facility failed to report a fall incident for one of three sampled residents (Resident 1) to the State Agency when Resident 1 was being transferred from wheelchair to bed using a Hoyer lift (a mechanical device used to lift and transfer residents with limited mobility from one surface to the other). One of loops/straps of the sling (a supportive fabric, shaped like a hammock which holds the residents. Loops of the sling are attached to the bars of the Hoyer lift) broke, causing Resident 1 to land directly onto the floor. Resident 1 hit his left leg onto the bottom bar (base) of the Hoyer lift, sustained a laceration (deep cut in the skin) on left shin, requiring transfer to the emergency room of an acute care hospital for staples (metal or plastic clips applied to close a tear in the skin). [...]

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to complete annual Minimum Data Set (MDS) assessments within 14 calendar days following the Assessment Reference Date (ARD), which affected 3 (Residents #14, #27, and #29) of 3 residents reviewed for annual MDS requirements.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed within 14 calendar days following the Assessment Reference day (ARD), which affected 3 (Residents #13, #16, and #22) of 3 residents reviewed for quarterly MDS requirements.

Inspectors wroteBased on record review, interview, and a review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for 1 (Resident #26) of 1 resident reviewed for hospice services.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop and implement a person-centered comprehensive care plan for 1 (Resident #167) of 21 sampled residents.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to transcribe and carry out treatment orders for 1 (Resident #42) of 21 sampled residents.

Inspectors wroteBased on interview, observation, facility document review, and facility policy review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 35 resident rooms.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received showers per shower schedule. Resident 1 received only one shower in more than two weeks long stay at the facility. This failure placed Resident 1 at risk for lack of cleanliness and comfort.

Inspectors wroteBased on interview and record review, the facility failed to administer Heparin Sodium Injection Solution 5000 Unit/ml (a medication used to prevent and treat blood clots and other clotting-related conditions) for one (Resident 1) of four sampled residents. This failure resulted in Resident 1 not receiving medications as per physician's orders and placing Resident 1 at high risk for developing a blood clot.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (Resident 20) of 12 sampled residents were free from unnecessary drugs when the interdisciplinary team did not evaluate Resident 20's use of Quetiapine {(seroquel) an antipsychotic drug} for appropriateness, adequate clinical rational and indication for continued usage. This failure had the potential for Resident 20 to receive unnecessary drugs and suffer adverse medication side effects.

Inspectors wroteBased on interviews and record review the facility failed to ensure the person designated to serve as Dietary Supervisor (DS) of food and nutrition services had the federal and/or state educational qualifications for the position. This deficient practice had the potential for lack of competency and skill set necessary to carry out all the functions of the food and nutrition services.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure food was served at a safe temperature when during lunch tray line curry lemon chicken was not served at appropriate temperature. This deficient practice placed residents at risk of non appetizing food temperature and a potential for food borne illness.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store and prepare food under sanitary conditions when the hand washing sink had a pinkish brownish substance around the faucets and the trash cart had a brownish substance around the open area. These failures had the potential to result in food borne illnesses.

Inspectors wroteBased on observation and interviews, the facility had two resident (Rt) rooms (Rooms A and B) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents' belongings.

Inspectors wroteBased on observation, interview, and record reviews, the facility used bed rails and a position change alarm (bed alarm) for the convenience of staff, to prevent one of 13 residents (Resident 48) from voluntarily leaving his bed, and failed to re-evaluate the ongoing need for use of the restraining devices. This failure resulted in psychological and emotional distress for Resident 48, who was afraid to move around in bed, and had the potential to result in injury if he became entangled in the bed rails, or attempted to climb over the bed rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe food practices when: 1. Unpasteurized eggs were used to make soft-yolk, fried eggs for residents. 2. Freezer 2 had a temperature above zero degrees Fahrenheit (F): bread, waffles, and bread rolls inside the freezer were not solidly frozen; ice cream cups were liquified. 3. The facility ice machine had a white residue on the air intake filter. 4. The following items were stored unlabeled and undated, as follows: Refrigerator 2 had one 12-ounce jar of pickles with an unsealed lid; Freezer 1 had one unsealed box of 48 rainbow sherbet cups, and two individual 4-ounce cups of vanilla ice cream; Freezer 2 had one plastic bag of frozen enchiladas, sealed by knotting the plastic bag; four frozen bags of peas; one 32-ounce bag of frozen cauliflower; and five 40-ounce bags of frozen brussel sprouts; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed policy and procedures for hand hygiene for seven of 14 sampled residents (Residents 26, 35, 18, 30, 101, 2, and 49). The failure of Certified Nursing Assistant 1 (CNA) to perform required hand hygiene during the passing and setting up of the residents' lunch trays had the potential to result in illness, and the spread of illness for Residents 26, 35, 18, 30, 101, 2, and 49.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to close the privacy curtains around one (Resident 14) of 14 sampled residents' beds during care provision. This failure resulted in the exposure of Resident 14's genitals to her roommate, and passers-by in the hallway. This failure had the potential to result in emotional distress for Resident 14.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to fully inform the responsible party (RP) of the current dental health status of one of 13 sampled residents (Resident 25). This failure had the potential to result in Resident 25 developing an oral infection or gum disease, which could negatively impact her general health.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the correct documentation for refusal of treatment was present in the medical record of one of eight sampled residents (Resident 46). The facility failure to change the medical record, to reflect a change in the status of Resident 46's wishes for treatment in the event of a medical emergency, had the potential to result in the undesired life sustaining treatment of cardiopulmonary resuscitation. (CPR, an emergency procedure that combines chest compressions with artificial ventilation (mouth to mouth breathing, or assisted breathing through a tube inserted into the throat.)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide notification of the need to alter the dietary treatment for one of 14 residents (Resident 100). The failure to inform the physician of Resident 100's refusal, for four days, to complete the infusion of the ordered liquid tube feeding (provision of nutrition and hydration through a tube inserted into the stomach, for residents unable to orally ingest sufficient quantities to support daily needs), had the potential to result in weight loss, body chemistry imbalance, and negatively impact general health status.

Inspectors wroteBased on interview and record review, for two of 14 sampled residents (Resident 7 and Resident 32), the facility failed to develop and implement a comprehensive care plan to address: 1. Resident 7's need for assistance with activities of daily living (ADL, the activities of dressing, eating, hygiene, toileting, mobility, ambulation, and bathing), and use of psychotropic medications (medication used to modify mental and/or emotional states). 2. Resident 32's need for assistance with ADLs, and use of psychotropic medications. These deficient practices had the potential to result in Resident 7 and Resident 32 not receiving the appropriate medical interventions necessary to meet the residents' nursing care needs.

Inspectors wroteBased on interview and record review, for one of 14 sampled residents (Resident 100), the facility failed to provide nursing services that met professional standards of quality when Resident 100 refused to receive the complete ordered dose of tube feedings (medical device used to provide nutrition when a person has trouble eating) for 3 days, and the medical doctor (MD) had not even been notified. This deficient practice resulted in Resident 100 not receiving adequate nutrition through enteral feeding.

Inspectors wroteBased on observation, interview and record review, facility staff did not develop and implement a communication plan for a non-English speaker, for one of 13 sampled residents (Resident 14). For Resident 14, this failure had the potential to result in emotional distress, and unmet care needs.

Inspectors wroteBased on observation and interview, the facility had two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) with two beds each that provided less than 80 square (sq.) feet (ft.) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the resident belongings.