Canyon Transitional Rehabilitation Center, LLC

Inspectors wroteBased on observation, record review, and interviews, the facility failed to safeguard protected health information (PHI) for 4 (R #10, R #11, R #12, and R #13) of 4 (R #10, R #11, R #12, and R #13) residents. If the resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure staff properly stored and secured medications for all residents on the 300 hall when the hall medication cart (a mobile storage unit equipped with drawers and locking mechanisms to hold medications) was not secured and was left unattended. If the facility fails to secure medication carts, residents are likely to experience unauthorized access to medications, potentially resulting in injury or illness.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food was prepared, served, handled, and monitored under sanitary conditions when staff failed to: Complete required daily logs of the sanitizer bucket, three compartment sink, and the dish machine in the kitchen. Complete daily refrigerator and freezer temperature logs in the nourishment room. Properly seal and protect open food items to prevent air exposure inside the large refrigerator located in the kitchen. Properly store raw meat inside the large refrigerator located in the kitchen. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of at least 12 hours per year for 4 (CNAs #12, #13, #16 and #17) of 7 (CNAs #11, #12, #13, #14, #15, #16, and #17) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in CNA's not receiving the necessary training to meet the care needs of the residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop an accurate comprehensive, person-centered care plan for 1 (R #30) of 2 (R #1 and #30) residents reviewed for care planning, when facility staff failed to initiate a care plan to reflect R #30's behavioral health needs, including Suicidal Ideation (SI; thoughts, preoccupations, or plans about ending one's own life, ranging from fleeting considerations to detailed planning). This deficient practice is likely to result in residents being at risk for unmet needs, a decreased quality of life, and avoidable decline in physical and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to revise a care plan for 1 (R #70) of 1 (R #70) resident reviewed for feeding tube (medical device to provide nutrition to people who cannot obtain nutrition by mouth) use. If the facility is not updating the care plan to reflect the residents' current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the residents' needs.

Inspectors wroteBased on record reviews and interviews, the facility failed to prevent a significant medication error for 1 (R #84) of 1 (R #84) resident reviewed, when:The facility administered Tylenol (acetaminophen; pain medication) without a manufacturer's expiration date or date of opening on bottle. This deficient practice is likely to result in residents not receiving full benefit from medications, possible prolonged treatment period, or unwanted effects.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain a safe and sanitary environment to prevent the transmission of infectious agents and communicable diseases for 2 (R #4, and R #43) of 2 (R #4, and R #43) residents, when the facility: Failed to prevent a urinary catheter (a thin, flexible tube which drains urine from the bladder) bag and tubing from touching the floor for R #4. Placed an oxygen humidification container (device used to add moisture to dry oxygen gas before it is delivered to a patient) on the floor of R #43's room. These deficient practices have the potential to expose staff and other residents to infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to: - Store opened food with labels and dates to prevent cross contamination and outdated usage, - Store meat in a manner to prevent leakage and contamination of other food items, These failures had the potential to result in cross contamination and foodborne illness which could affect all residents who ate food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician or the nurse practitioner for 2 (R #29 and #132) of 2 (R #29 and #132) residents for: 1. R #29 who had significant amount of pain. 2. R #132 who did not receive several doses of his intravenous (IV; a tube inserted into a blood vessel and used to administer medications, fluids, or nutrition into the bloodstream) antibiotic. If the facility is not notifying the physician or nurse practitioner of changes in a residents medical condition then the resident will not receive prompt medical care and could cause a delay in treatment, unnecessary pain, and could create more serious health complications.

Inspectors wroteBased on interviews and observations, the facility failed to provide a clean, homelike environment for all 21 residents who lived on the 400 hall. This deficient practice is likely to result in residents not feeling comfortable, which could affect their psychological well-being.

Inspectors wroteBased on record review and interview, the facility failed to provide care that met professional standards for 1 (R #60) of 3 (R #23, #60 and #16) residents when the facility failed to maintain and care for R #60's gastrostomy tube (g-tube; a tube surgically inserted through the abdomen into the stomach and used to provide fluids, nourishment and medications.) This deficient practice is likely to result in residents not receiving proper nutritional needs and also places residents at risk for complications and infections that may affect their quality of life.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed 5 percent (%) for 7 residents (R #25, #32, #52, #130, #131, #132, and #317) of 11 residents (R #3, #16, #25, #31, #32, #45, #52, #130, #131, #132, and #317) reviewed during medication administration. Staff administered 80 medications with 39 errors, which resulted in a medication error rate of 48.75 %. If medications are administered in error, residents are likely to experience less than optimal results from their medication regimen.

Inspectors wroteBased on record review, observation, and interview, the facility failed to keep a resident free from significant medication errors for 1 (R #132) of 1 (R #132) residents when they failed to administer R #132's vancomycin (an antibiotic medication) intravenous (IV; a tube that is inserted into a blood vessel and used to administer medications, fluids, or nutrition into the bloodstream) medication in a timely manner as per the physician's order. This deficient practice is likely to cause R #132 to have adverse drug effects including but not limited to lowering the effectiveness of the antibiotic treatment and potentially contributes to antimicrobial resistance (when microorganisms, like bacteria, viruses, fungi, and parasites, change and are no longer affected by the drugs used to treat them).

Inspectors wroteBased on observations, interviews and record review, the facility failed to: 1. Ensure medication refrigerators did not contain medications that belonged to discharged residents. 2. Ensure nurses and CMAs dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) vials and discarded them within 28 days of opening. 3. Ensure medication carts did not contain medications that belonged to discharged residents. These deficient practices are likely to result in residents receiving medications that are less effective or expired for all 70 residents who reside in the facility, as identified on the census list provided by the facility Administrator on 11/25/24. The findings for the medication refrigerator: A. On 11/26/24 at 10:50 am, during observation of medication refrigerator located inside the medication room, revealed the following: [...]

Inspectors wroteBased on record review and interview the facility failed to ensure advance directives (a document which provides an individual's wishes for emergency and life saving care) were complete for 1 (R #45) of 1 (R #45) resident reviewed for advance directives when staff failed to ensure the resident signed the advance directive. This deficient practice is likely to result in residents receiving unwanted or unplanned treatment during a medical emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff completed the comprehensive care plans for 2 (R #23 and R #166) of 2 (R #23 and R #166) residents reviewed for care plans, when staff failed to: 1. Complete care plans for R #23 for the following areas: Activities of daily living (ADL; basic self-care tasks) care, psychotropic medications (medications that affect behavior, mood, thoughts and perception), and respiratory complications; and 2. Complete care plans for R #166 for the following areas: ADL care, cardiovascular (heart) symptoms or complications, oral health, diabetes (high blood sugar levels), anemia (not having enough healthy red blood cells), and anticoagulant (medication that thins the blood) medication use. This failure has the potential to adversely affect staff's ability to implement preventative measures for the residents' health and well-being.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide adequate and timely pain relief for 1 (R #29) of 2 (R #29 and #132) residents reviewed for pain. This deficient practice likely resulted in R #29 to be in significant pain.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain proper infection prevention practices when a staff did not perform hand hygiene prior to and after handling medications for 1 (R #132) of 1 (R #132), This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the 23 residents in 100 hall.

Inspectors wroteBased on observation and interview, the facility failed to maintain an environment that was clean and homelike for 2 (R #7, R #8) of 2 (R #7, R #8) residents reviewed for homelike environment. This failure had the potential to affect all 69 residents identified on the resident census provided by the administrator on 10/30/31. If the facility fails to maintain resident rooms in a safe and homelike environment then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff maintained accurate medical records for 1 (R # 3) of 7 (R # 1, R # 2, R # 3, R #4, R #5, R #6, and R #7) reviewed for charted pain medications in the electronic medication administration record (EMAR). This deficient practice could likely result in residents receiving more narcotic [a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep, but in excessive (more than necessary) doses causes coma (a deep state of not being awake or aware of things around you), convulsions (a medical condition in which muscles contract and relax rapidly and repeatedly resulting in uncontrolled shaking), or seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness)].

Inspectors wroteBased on record review and interview, the facility failed to notify the Ombudsman (long term care advocate for residents) in writing with the reason for the transfer/discharge to the hospital for 1 (R #61) of 1 (R #61) residents. This deficient practice is likely to cause the resident the inability to make informed decisions about the resident's care and not have access to an advocate who can inform them of their options and rights.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to provide services that meet professional standards for 3 (R #18, R #63, and R #135) of 3 (R #18, R #63 and R #135) by: 1. Staff did not follow physician orders (R #135), 2. Staff did not document urine output for a resident with severe chronic kidney disease (R #63); 3. Staff did not provide a swallow evaluation and treatment services for a resident with swallowing difficulties/dysphagia (R #18) when indicated. These deficient practices may cause aspiration of a liquid causing the resident to choke if staff do not follow physicians' orders, progressing kidney failure could be occur without staff or the physician being aware if resident urinary outputs are not documented, and choking and aspiration if swallowing difficulties are not screened and treated.

Inspectors wroteBased on observation and interview, the facility failed to serve food under sanitary conditions by: 1. Not ensuring all food items of residents' plated meals were covered while being transported from the the meal cart in the hallway into residents' rooms for in-room dining. 2. Not using proper handling techniques when handling cups and glasses when drinks were distributed to residents dining in their rooms. 3. Gloves not being removed and hands not being sanitized by staff. These deficient practices are likely to affect all 70 residents listed on the resident census list provided by the Administrator on 08/14/23 and could likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide infection control practices by not: 1. Performing hand hygiene between residents 2. Changing out gloves between direct care 3. Not Donning (applying personal protective equipment) and Doffing (taking off PPE) between residents on isolation 4. Cleaning the glucometer (an instrument used to measure sugar in the blood) after resident use. These deficient practices could likely result in the spread of infectious agents (viruses and bacteria) between the residents and/or staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify and give written notification to residents for 2 (R #7 and R #48) of 2 (R #7 and R #48) residents reviewed for notification of room change. This deficient practice could likely result in a resident being unprepared for the room change and may lead to feelings of helplessness, anxiety, and frustration.

Inspectors wroteBased on observations, record review, and interview the facility failed to provide a safe environment free of hazards for 4 (R #31, 29, 121, and 164) of 4 (R #31, 29, 121, and 164) residents reviewed for accident hazards due to: 1. A floor mat that was on the floor in a residents room while the resident wasn't in bed R #164, 2. A wheelchair weight machine not being folded and in it's locked position taking up a large portion of the hallway; 3. By not providing one resident with her helmet when she was out of bed for R #121. [...]

Inspectors wroteBased upon observation, record review, and interview, the facility failed to meet professional standards of care for 4 (R #11, R # 39, R #166, and R #168) of 4 (R #11, R # 39, R #166, and R #168) residents reviewed for respiratory care by: 1. Not properly dating and monitoring the oxygen delivery tubing for R #166, R #11, and R #39; and dating the humidifier bottle (bottle of water that provides water to the oxygen to prevent the air from being too dry) for R #168 and R #166. These deficient practices could lead to hypoxia (decreased oxygen to the body) by not supplying enough oxygen and could lead to possible respiratory infections by the oxygen tubing becoming clogged, filled with water condensation, or becoming dirty leading to the reduced flow of oxygen. R #168 A. On 08/15/23 at 10:37 AM, during an observation, R #168 was observed to be taking oxygen. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 1 (R #134) of 1 (R #134) resident reviewed for dialysis. If the facility is unaware of residents status, current condition, or any barriers or complications, then residents are likely to not receive the appropriate monitoring and care they need.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain records of controlled substances (drugs that are subject to strict government control because they may cause addiction) on each medication cart. This deficient practice could case the likelihood of controlled substances being diverted (a medical and legal concept including the transfer of any illegal prescribed controlled substances from the individual for whom it was prescribed to another person for any illicit use) and expired medication was found in the medication storage room.

Inspectors wroteBased on interview and record review, the facility failed to obtain laboratory testing for 1 (R #6) of 1 (R #6) residents reviewed for laboratory services. If the facility fails to obtain labs that have been ordered, this could likely cause a delay in services related to her anticoagulant therapy, (commonly known as blood thinners) causing harm to the resident.

Inspectors wroteBased on observation and interview, the facility failed to promote care with dignity and respect, for 1 (R #36) of 1 (R #36) resident reviewed, by attempting to restrict R #36's interactions with another resident (R #50) under threat of discharge from facility. This deficient practice could likely result in feelings of living in a hostile environment and feelings of helplessness and fear.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents were aware of and/or understood the risks and benefits of medication they were receiving for 1 (R #11) of 1 (R #11) residents by not informing residents of why a medication was being prescribed and administered and what diagnosis/condition it was treating. This deficient practice could likely result in residents feeling anxious and potentially receiving unnecessary treatment/medication.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive person care plan for 1 (R #6) of 1 (R #6) residents. Failure to develop and implement a person-centered care plan could likely result in staff's failure to understand the needs and implement the appropriate treatments for residents; possibly resulting in decline in abilities and failure to thrive.

Inspectors wroteThis is cited at Past Non-compliance Based on record review and interview the facility failed to initiate a change in condition prompting the physician to be notified for 1 (R #63) of 5 (R # 29, 34, 47, 63 and 120) residents looked at for change in condition. This deficient practice could likely contribute to residents suffering a decline in their health, hospitalization, and death if a change in condition is not identified timely.

Inspectors wroteBased on record review and interview the facility failed to ensure a residents feeding tube was properly taken care of for 1 (R #121) of 1 (R #121) reviewed for feeding tubes. This deficient practice could likely cause infection at the site of the feeding tube if there are no physician orders to continue to clean the area around the feeding tube; and the order to remove the feeding tube had not been followed through with.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that food was prepared in a form that met a resident's required textured diet (an appropriate consistency of food that can be easily chewed and swallowed) for 1 (R #18) of 1 (R #18) resident observed during random observation. This deficient practice could likely result in a choking incident.

Inspectors wroteBased on interview and record review the facility failed to have complete and up to date resident records for 1 (R #62) of 1 (R #62) resident looked at for discharge. This deficient practice could cause confusion if minimal documentation is found in the chart for a resident who left Against Medical Advice (AMA).