Canyon Springs Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice for one of three residents (Resident 1), when a medication was ordered with no indication for use identified. This failure had the potential to compromise Resident 1's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one of four residents (Resident 1) on oxygen therapy when Resident 1's BiPAP (a breathing support method that delivers positive pressure to the lungs through a mask) application was not documented by licensed nurses. This failure had the potential to result in inadequate monitoring of the resident's condition, and the potential to negatively affect the residents' health, safety and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when: 1. Staff did not use proper gloving technique during a wound dressing change when hand hygiene was not properly performed for Resident 13; 2. Resident 54's urine drainage bag was not covered with a protective bag and was not kept off the floor; 3. Residents' used basins, bed pans and a urinal were unlabeled and stored on top of residents' bathroom toilet tank and under the bathroom sink beside a garbage container; 4. Registered nurse Z (RN Z) used contaminated (something has become impure or unsuitable due to contact with something unclean, harmful, or undesirable) gloves to administer Resident 151's eye drops to both eyes; 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of 35 sampled residents (Residents 77, 175, and 57) were free from chemical restraints (the use of medications such as psychotropic medications [drugs that affects brain activities associated with mental processes and behaviors, example is antipsychotics, antidepressants, anti-anxiety, hypnotics] not for therapeutic reasons, but to restrict a person's freedom of movement or control their behavior) when: 1. Resident 77 continued to receive lorazepam (brand name: Ativan; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated resident assessment tool) assessments for one of 35 sampled residents (Resident 158) when Resident 158's five MDS assessments did not reflect Resident 158's feeding tube (a medical device, a thin and flexible tube, used to deliver nutrition and fluids directly into the digestive system when a person cannot eat or drink safely by mouth) and the percentage of intakes by artificial route. These failures resulted in inaccurate MDS assessments and had the potential to affect the residents' care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards for two 11 sampled residents for medication administration (Residents 88 and 192) when: 1. Licensed vocational nurse I (LVN I) provided the wrong nutritional supplement (Boost Plus - brand name of the nutritional supplement) to Resident 88; 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an account of all controlled drugs (medications with high potential for abuse and addiction) was maintained and reconciled for four of six randomly selected residents (Residents 137, 3, 135, and 16) when: 1. Nursing staff signed out the controlled drugs from the Controlled Substance Accountability Sheet (CSAS - an inventory sheet that keeps record of the usage of controlled medications) but did not document on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) to indicate the controlled medications were given to the resident (Residents 16). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 9.68% when three medication errors were observed out of 31 opportunities during medication administration for three of 11 residents (Residents 9, 193, and 79) when: 1. Resident 9 received the second dose of albuterol sulfate (an inhaler used to treat or prevent bronchospasm, or narrowing of the airways in the lungs) inhalation (or puff, the act of taking a substance into the body by breathing) without having to wait for one minute for first inhalation to be fully absorbed by the lungs; 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored and labeled in two of four medication rooms and in four of seven medication carts when: Multiple opened inhalers, medications, and nasal sprays did not have an appropriate label of resident's named in the bottle or inhaler; [NAME]-dose vials were not labeled with open dates, or with an accurate expiration date, or being used past their discard dates; Opened or used eyedrops did not have a readable resident's name or had an unreadable open and expiration date; Multiple expired home medications were still stored in residents' overflow bin together with other medications that were still within the used by date; An expired over the counter (OTC) medication was still stored with other new OTC medications; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure clinical records were accurately and timely documented for two sampled residents (Resident 86 and Resident 595) when: 1. Resident 86's Discharge Order and Progress Notes were documented late. 2. Resident 595's Interdisciplinary Team Meeting (IDT, involves various healthcare professionals collaborating to plan and coordinate a resident's care) notes were documented late. These failures resulted in an inaccurate presentation of information.

Inspectors wrote2. A review of Resident 591's medical record indicated an admission Date of 4/17/25. Resident 591's diagnoses included cognitive communication deficit (trouble communicating because of problems with their thinking and processing abilities, not just their language skills), and dysphagia, oral phase (difficulty with the first stage of swallowing, which happens in the mouth). A review of Resident 591's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 591's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 13 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During a concurrent observation and interview on 5/5/25 at 8:56 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plans that included target symptoms, measurable objectives, and interventions for one of 35 sampled residents (Resident 16) when there were no care plan developed for schizophrenia (chronic brain disorder that affects how a person thinks, feels, and behaves). The failure had the potential for the residents not attaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure administration of enteral feeding (the delivery of nutrients through a feeding tube directly into the stomach) was consistent with and followed Physician's Order for one (Resident 51) out of three sampled residents when insufficient amount was administered, and oral care was not done. These failures had the potential to put Resident 51 at risk for dehydration, weight loss and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a proper treatment services for oxygen (O2, a colorless, odorless gas) therapy was provided for one of four sampled residents (residents on oxygen therapy) when Resident 139 did not receive the correct flow of oxygen administration. This deficient practice had the potential for Resident 139 to have complication related to improper treatment while receiving O2 therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for one of 35 sampled residents (Resident 57) resident who used side or bed rails when there was no physician's order for bilateral (both) quarter upper bed rails prior to installing the bed rails, the care plan for bilateral quarter upper bed rails was not developed in a timely manner, and the informed consent for bilateral quarter upper bed rails was not obtained prior to installing the bed rails. These failures had the potential risk for injuries to the Resident 57. During an observation in Resident 57's room on 5/5/25 at 9:44 a.m., Resident 57's bed observed with bilateral quarter upper bed rails were up. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of 35 sampled residents (Resident 160) received the planned menu meal or the food alternative, as indicated on the posted menu and consistent with the resident's preferences. As a result, Resident 160 did not receive the correct food items on multiple occasions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a visible and audible alarm activated by a call button) for two of 35 sampled residents (Resident 55 and Resident 148) was within reach. This deficient practice had the potential to result in a delay in meeting Resident 55 and Resident 148's needs for toileting and activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed to ensure lab results were communicated to the physician for one of three sampled residents (Resident 1). This failure had the potential to delay treatments and interventions that Resident 1 may have needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented in four out of six shower rooms when: 1. Shower room [ROOM NUMBER] had a brown substance on the floor; 2. Shower room [ROOM NUMBER] had cotton swabs and a shaver cover on the floor drain; 3. Shower room [ROOM NUMBER] had a used white towel on the shower handlebar, and 4. Shower room [ROOM NUMBER] had a used shaver, toilet tissue, wheelchair footrests, and socks in the bathtub. These failures could result in the spread of infection and cross-contamination that could affect staff, visitors, and the 194 residents who reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to notify a responsible party (RP, person who makes healthcare decisions on behalf of a resident) regarding change in condition (clinically important change of a person's health status) when a resident sustained an injury to his left elbow for one of three sampled residents (Resident 1). This failure resulted in the RP not being informed.

Inspectors wroteBased on interview and record review the facility failed to ensure staff provided treatment and care in accordance with professional standards of practice when Resident 1's: 1. physician's orders were obtained late for wound treatments, and these orders were then implemented late, 2. physician's order for the right third toe was not obtained, 3. change of condition (clinically important change of a person ' s health status) was not documented regarding a (3a.) a STAT (urgent) lab that was ordered and (3b.) elbow wound, 4. clinical record lacked documentation relevant to an elbow wound. These failures placed the resident's health at risk.

Inspectors wroteBased on interview and record review the pharmacist failed to report drug irregularities for one of four sampled residents (Resident 1), when Resident 1 received a diuretic (Lasix) with a black box warning (BBW, medications identified by the Food and Drug Administration (FDA) to have serious side effects to alert consumers) label; however, the consultant pharmacist (CP) did not address side effects monitoring for it. This failure left the potential side effects of Lasix to be unmonitored for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure a STAT (urgent) laboratory result was obtained timely for one of three sampled residents (Resident 1). Resident 1's STAT laboratory order was not obtained until a day after it was ordered and one test result had a critical value (potentially life-threatening requiring immediate medical attention). This failure resulted in a delay in hospital transfer and placed the resident's health at risk.

Inspectors wroteBased on interview and record review the facility failed to promptly notify an abnormal lab result to the physician/nurse practitioner (NP) for one of four sampled residents. This failure resulted in the delay of the resident's change in prescription.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded. Specifically, MDS assessments did not reflect the use of oxygen for 1 (Resident #34) of 4 sampled residents reviewed for respiratory care and did not accurately reflect the discharge location for 1 (Resident #183) of 6 sampled residents reviewed for hospitalizations.

Inspectors wroteBased on record review, interviews, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to ensure 1 (Resident #117) of 8 sampled residents reviewed for PASRR requirements was referred for further evaluation after the addition of a new mental illness diagnosis.

Inspectors wroteBased on record review, interviews, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASRR) Level 1 Screening for 1 (Resident #117) of 8 sampled residents reviewed for PASRR requirements. Specifically, the facility failed to ensure Resident #117's PASRR Level 1 Screening reflected the resident's diagnosis of major depressive disorder.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure 2 (Resident #106 and Resident #128) of 33 sampled residents' care plans reflected the residents' current conditions and needs.

Inspectors wroteBased on interview and record review, the facility failed to provide services in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. Licensed nurses did not complete Resident 1's quarterly fall risk assessment; 2. Licensed nurses did not document the assessment and reassessment of skin discolorations that were discovered on Resident 1's body; and 3. Licensed nurses did not accurately complete Resident 1's Nursing Weekly Summaries (weekly assessments of the resident's overall condition). These failures had the potential to compromise the facility's ability to provide resident-centered interventions based on assessment data.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge for one of three randomly selected discharged sample residents (Resident 14) when: 1. The facility did not initiate a discharge care plan for Resident 14; 2. The interdisciplinary team (IDT, leaders from different departments discuss the resident's care) did not assess the safety of Resident 14's discharge; Facility discharged Resident 14 to the street and left the resident alone in the street; alone; Facility did not know the Resident 14's whereabouts after the discharge; 3. IDT team members were not involved in the resident's discharge; 4. The facility did not provide Resident 14 the instruction and education for the after discharge care; 5. The facility did not involve the responsible party (RP, a person who is designated to make the care decisions for the resident) regarding the discharge; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper infection control practices when: 1. Multiple residents did not wear their face masks properly when they were outside the room; 2. Dirty hamper in the hallway was overflowing with linens; 3. Electric fan on top of the Room J has grayish substance inside and out; 4. Residents 51, 61 and 84's oxygen concentrator filters were dusty; 5. There were no documents that indicated multiple residents refused Coronavirus Disease 2019 vaccine (COVID-19, a respiratory disease spreads from person-to-person through respiratory droplets produced when an infected person coughs, sneezes, or talks); 6. Incomplete Visitor Respiratory Screening Questionnaires for COVID-19; 7. Multiple facility staff did not maintain infection control practices; 8. The facility staff did not maintain droplet precaution practice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate residents' needs for six of 31 sampled residents (Residents 22, 43, 60, 110, 122, and 563) when: 1. Four residents' call lights (Residents 43, Resident 122, Resident 563 and Resident 60) were not functioning for four consecutive days; 2. Facility staff did not answer Resident 22's call light in a timely manner to assist her with bowel care; 3. Resident 110 was using the small size incontinent brief pad instead of the proper large size; 4. Resident 60 was using a wheelchair that was not fitted for him. These failures had the potential to result in the residents' needs being unmet and affecting residents' well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan for four of 31 sampled residents (Residents 134, 150, 560 and 566). This failure had the potential to result in the facility being unable to identify residents' individualized concerns/needs and outline the care and services required to meet the residents' identified needs.

Inspectors wrote4. During observation and record review of Resident 7's face sheet on 6/8/21 at 8:50 a.m., Resident 7 was awake and resting in bed. Resident 7 has a BIMS score of 14. Resident 7 has a history of heart failure (heart struggles to work properly), asthma (respiratory condition making breathing more difficult), chronic obstructive pulmonary disease (respiratory condition making breathing more difficult), and chronic bronchitis (respiratory condition making breathing more difficult). During an observation, interview, and record review with licensed vocational nurse H (LVN H) on 6/8/21 at 8:50 a.m., LVN H gave Resident 7 the Spiriva inhaler and gave no instruction on administration. Resident 7 inhaled the medication and immediately exhaled. LVN H confirmed the order for Spiriva 18mcg daily at 0800. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, revise, and update an individualized and comprehensive person-centered care plan with measurable objectives, goals and person-centered interventions for four of nine sampled residents who had falls or risk for falls (Residents 3, 41,102 and 143) These failures had the potential to put the residents at risk of sustaining injuries and falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician's orders regarding gastrostomy tube (GT, a soft tube surgically inserted from the abdomen area into stomach for medication and nutrition use) feeding for three of seven residents (Residents 52, 77 and 114). This failure had the potential to result in complications of tube feeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the peripherally inserted central catheter (PICC, a thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart to obtain intravenous access for medication administration) line care for three of four residents (Residents 150, 555 and 566) were done per professional standards of practice when: 1. Registered nurses (RNs) did not follow the physician's orders of the PICC line flushing for two of four residents (Residents 555 and 566). 2. Licensed nurse did not notify MD (doctor of medicine) when Resident 555's PICC line was pulled out and the IV antibiotics were not administered on time. 3. Registered nurses did not change the PICC line dressing as ordered for two of four residents (Residents 150 and 555). 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dialysis services consistent with professional standards and to ensure staff had coordinated a resident's care with the dialysis facility for one of nine sampled residents (Resident 32) who received hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e. salts and mineral imbalances by using a machine and an artificial kidney) when: 1. Communication with the dialysis facility center was not properly coordinated when dialysis communication records (DCR) were not completed; 2. Staff was not trained on emergency care for residents with renal diseases, dialysis care and there was no emergency dialysis kit available, and; 3. The dialysis care plan was not resident-centered. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure accurate accountability and storage of controlled substance (CS) medications (drugs with high potential for abuse or addiction); and the security of medications stored in the automated drug dispensing system (ADDS, a mechanical system that performs operations or activities, other than compounding or administration, relative to the storage, dispensing, or distribution of drugs) according to the facility policy and procedures, when: 1. The amount of oxycodone (a potent CS medication for pain) liquid for Resident 30 was inaccurate; 2. A CS medication for a discharged resident was transferred from the pharmacy's original packaging and without any identifiers; 3. [...]

Inspectors wrote2. During concurrent observation and interview with licensed vocational nurse H (LVN H) on 6/8/21 at 8:56 a.m., LVN H applied a nitroglycerin transdermal patch to Resident 7's left upper arm. LVN H failed to check Resident 7's skin to make sure the previous nitroglycerin patch had been removed prior to the application of the new patch. Shortly after the medication administration, LVN H stated another shift was responsible for removal of the patch. LVN H stated she should have checked prior to putting it on and confirmed the failure to remove it, and the application of an additional patch can result in extra medication being delivered by the medication patch. LVN H then checked Resident 7's left upper arm, found another undated nitroglycerin patch on Resident 7's upper left arm, and removed the older nitroglycerin patch. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three medication refrigerators (Refrigerators #1 and #2) were within the accepted range of 36 to 46 degrees Fahrenheit (ºF). Also, the staff failed to take appropriate actions, such as notification to the director of nursing or maintenance, when the temperature was out of range. This failure had the potential for medications to lose their potency and effectiveness when administered to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. Four dietary staff did not cover their hair completely with a hairnet; 2. One pair of used gloves was on top of the kitchen cart; 3. Dietary staff did not do hand hygiene after touching his hairnet and face shield; 4. Dietary staff dropped his face shield on top of the kitchen table and did not disinfect the food preparation table and 5. Two out of four chopping boards had multiple deep cuts. These failures had the potential to cause food-borne illness for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat Resident 68 with dignity and respect when staff did not ask permission and provide privacy when requested to show Resident 68's right hip wound. This failure had the potential to cause emotional distress to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the licensed staff or interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) assessed and developed care plans for two of 31 sampled residents (Residents 97 and 150) regarding their abilities to self-administer of their own medications. These failures had the potential for improper medication administration and not addressing their clinical conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a sanitary, orderly and comfortable environment for six of 31 sampled residents (Residents 27, 34, 95, 110, 117, and 563), when: 1. Toilet seat and tanks were not securely installed for Rooms G, H and I. 2. Television (TV) reception was blurred for Residents 110 and 117. 3. There was no adequate bedroom space for Resident 563. 4. The walls of Room E and Room F were unmaintained. These failures had the potential to result in affecting the residents' safety, emotions, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) Section N (Medications) for one of 31 sampled residents (Resident 568). This failure had the potential to result in unmet care needs for Resident 568.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the individualized and comprehensive care plans to meet individual needs for three of five reviewed residents (Residents 68, 88 and 136). This failure had the potential to result in not meeting the resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and treatment for one of 31 sampled residents (Resident 68) when the treatment nurse (TX) did not follow the physician's order for the right hip pressure ulcer (PU, skin injury caused by unrelieved pressure resulting in full thickness tissue loss with exposed bone, tendon or muscles) treatment, and staff did not apply the heel protector/bootee (a device to help prevent pressure injury per Resident 68's care plan. These failures could compromise Resident 68's PU wound healing and possible recurrence of his healed right heel PU.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bladder care was provided for one of two residents (Resident 30) who had an indwelling urinary catheter (hollow tube that is inserted into the bladder to drain urine) when Resident 30's urinary collection bag was not emptied on the day shift. This failure had the potential to cause the resident's urinary tract infection (when bacteria gets into urine and travels up to the bladder).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective pain management for one of 31 sampled residents (Resident 120) when the attending physician was not informed when the resident's pain was not relieved after the PRN (as needed) pain medication was administered, and there was no pain management care plan developed. These failures could result in Resident 120 having ineffective pain management.

Inspectors wroteBased on interview and record review, the facility failed to provide medically-related social services for one of three randomly reviewed discharged residents (Resident 14) when social services (a department aiming to promote welfare of the residents in a facility) failed to: 1. Initiate a discharge care plan; 2. Include in the discharge process the responsible party (RP) and the interdisciplinary team (IDT, leaders from different departments to discuss the resident's care) in discharge planning; 3. Follow the physician's orders regarding the discharge; 4. Pursue other options outside of family, shelter, or street for discharge; 5. Arrange for necessary supplies and after care/follow-up for Resident 14. These failures resulted in the facility unsafely discharging Resident 14 to a local street corner at two streets with a walker on 6/7/21. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 12 residents (Residents 11 and 14) were free from unnecessary medications when behaviors were not monitored correctly for Seroquel and behavior monitoring for Geodon was not updated when the Geodon dosage was increased. This failure had the potential of an incorrect dosage being administered and the residents received unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 79) were offered and/or received influenza vaccination. This failure had the potential to place the resident at risk of becoming infected with influenza.