Canyon View Care Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent the occurrence or recurrence of pressure injuries for one (#12) of three residents reviewed out of 24 sample residents. Specifically, the facility failed to:-Ensure complete and thorough documentation of weekly wound assessments to track the progression of a chronic pressure injury for Resident #12; and,-Ensure recommendations provided by the outpatient wound clinic provider were followed for the chronic pressure injury for Resident #12.

Inspectors wroteBased on interviews, record review and observations, the facility failed to ensure residents were free from accidents or hazards for one (#14) of three residents reviewed for accident hazards out of 24 sample residents. Specifically, the facility failed to prevent the elopement of Resident #14.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#2 and #3) of three residents reviewed for abuse out of three sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #2 and Resident #3 from physical abuse by Resident #1.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an effective pest control program so the environment was free of pests. Specifically, the facility failed to prevent and take adequate measures to eliminate mice within the facility.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that one (#1) of three out of six sample residents was kept safe and free from elopement. Resident #1 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (a chronic, progressive neurological condition) with dyskinesia (involuntary movements). A wander/elopement risk evaluation, completed upon the resident's admission on [DATE], revealed Resident #1 had no previous elopement attempts and was not at risk for eloping or wandering. Resident #1's record review revealed the following attempted and successful elopements after admission: On 9/4/24, a progress note revealed Resident #1 left the facility through the South Short Hall emergency exit and was verbally redirected inside. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Implement an effective water management plan; and, -Ensure housekeeping staff properly sanitized resident rooms.

Inspectors wroteBased on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive and at the appropriate temperature. Specifically, the facility failed to ensure food was palatable and attractive when delivered to residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and two of two kitchenettes. Specifically, the facility failed to: -Ensure residents were offered and provided hand hygiene before meals; -Ensure the kitchen staff appropriately cleaned thermometers before temperatures were obtained from ready-to-eat foods; and, -Ensure cold foods were held at 41 degrees Fahrenheit (F) or below before serving residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the money from personal funds accounts was managed adequately for two (#7 and #13) of five residents reviewed for personal funds out of 41 sample residents. Specifically, the facility failed to notify Resident #7 and Resident #13, who were Medicaid funded, or their legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit for one person.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents' personal privacy for two (#18 and #49) of three residents reviewed for privacy out of 41 sample residents. Specifically, the facility failed to ensure residents had privacy during personal phone calls.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were kept free from abuse for one (#29) of four residents reviewed for abuse out of 41 sample residents. Specifically, the facility failed to protect Resident #29 from physical abuse by Resident #44.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide treatment and services to maintain hearing in a timely manner for one (#3) of one resident reviewed out of 41 sample residents. Specifically, the facility failed to ensure recommendations for Resident #3 were followed after an audiologist appointment.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals for one (#49) of two residents reviewed for pain out of 41 sample residents. Specifically, the facility failed to: -Consistently and accurately assess Resident #49's pain to ensure the resident's pain was at or below the resident's stated tolerable pain level; -Ensure Resident #49's care plan included person-centered non-pharmacological interventions for pain; and, -Ensure the physician's order for routine pain medication for Resident #49 was administered as ordered.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four out of five staff reviewed. Specifically, the facility did not complete annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for two (#176 and #40) of three residents out of 41 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure Resident #176 and Resident #40 and/or their representatives understood the agreement before signing the arbitration agreement; and, -Ensure staff reviewing the arbitration agreement with Resident #176 and Resident #40 and/or their representatives understood the components of the agreement.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an environment for residents, staff and the public that is safe, functional, sanitary and comfortable. Specifically, the facility failed to ensure appropriate communication occurred regarding the facility's [AGE] year old hot water heater. The facility's failure to address the concerns timely resulted in the hot water heater failing and the facility was without hot water to provide a comfortable bathing experience for residents during a three week time period.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#12, #13 and #18) of eight residents reviewed out of 19 sample residents were provided personal privacy during care. Specifically, nursing staff failed to: -Ensure privacy during medication administration and treatment for Resident #13; -Ensure staff pulled the privacy curtain and/or closed the door while Resident #18 was getting dressed; and, -Ensure privacy during nail care for Resident #12.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#3) of three residents reviewed for dementia care received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being out of 19 sample residents. Specifically, the facility failed to: -Prevent Resident #3 from eloping the facility; -Have a procedure in place for the nurses to know which residents needed supervision when leaving the facility and which residents were able to independently leave the facility; and, -Ensure Resident #3 was assessed appropriately for his elopement risk.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for seven (#32, #40, #49, #56, #57, #71 and #226) of nine residents reviewed for abuse out of 41 sample residents. Specifically, the facility failed to ensure Resident #32 was free from physical harm and mental anguish. Resident #32 was hit repeatedly in the face by Resident #56 on 12/18/22, resulting in facial lacerations, swelling, and feelings of fearfulness and anxiety. Resident #56 continued to exhibit intimidating behaviors towards that resident in the days following the 12/18/22 altercation. In addition, the facility failed to ensure Resident #40, Resident #49, Resident #57, Resident #71 and Resident #226 on the secured/memory care unit were free from resident-to-resident altercations.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide adequate nutrition and hydration to one (#43) of eight residents reviewed out of 41 sample residents. Resident #43 received hospice services and was documented to have unavoidable weight loss. However, the facility failed to assess Resident #43's dietary and drink preferences, assess and implement dietary interventions, provide fortified foods as recommended by the registered dietitian, and provide food and drink access to ensure the resident received the assistance needed for his comfort, enjoyment and dignity, and to ensure he did not go hungry and thirsty. These failures contributed to Resident #43 experiencing severe weight loss within the previous month, and within the previous five months after his admission to the facility.

Inspectors wroteBased on interviews and record review, the facility failed to take action to resolve grievances of the resident council group, affecting 10 (#34, #24, #22, #23, #35, #60, #62, #54, #7 and #68) of 41 sample residents, and potentially affecting all the residents who lived in the facility. Specifically, the facility failed to follow-up with concerns that were brought up by the group of residents during the resident council meetings.

Inspectors wroteBased on observations and interviews, the facility failed to consistently ensure a safe, clean, comfortable, homelike environment in resident rooms, shower/tub rooms and common areas in four of four neighborhoods. Specifically, the facility failed to ensure: -Resident rooms and bathrooms were properly cleaned and maintained; -Wash cloths and towels were available in residents' bathrooms; and -Shower/tub rooms were functional, safe and properly cleaned. Cross-reference F565, grievances of the resident group.

Inspectors wroteBased on record review and interviews, the facility failed to ensure level I and level II preadmission screening and resident review (PASRR) were completed for four (#4, #5, #37 and #57) out of five residents reviewed for PASRR to gain and maintain their highest practical medical, emotional, and psychosocial well-being out of 41 sample residents. Specifically, the facility failed to: -Ensure Resident #37, with a known psychological disorder, was properly assessed with a PASRR level I or level II assessment; -Ensure Resident #5 and #57 had a level I PASRR screening completed timely; and, -Have the training and knowledge to follow up with PASRR screening identified concerns for Resident #4.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide and deploy sufficient nursing staffing to meet the needs of residents in keeping with their comprehensive care plans, and ensure their highest practicable quality of care. Specifically, the facility failed to provide sufficient staffing to provide a dignified and respectful resident environment, keep residents free from abuse, prevent falls and accidents, provide adequate nutrition and hydration, and provide dementia care and services.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for six (#32, #40, #56, #57, #71 and #226) of nine residents reviewed for mood and behavior out of 41 sample residents. Specifically, the facility failed to effectively identify and implement person-centered approaches for dementia care to prevent resident-to-resident altercations. Cross-reference: F600 failure to prevent resident abuse. Specifically, to create an environment to: -Provide consistent and engaging group activities when routine activity was not available; and, -Ensure the activity environment was appropriate for all residents in the memory care unit based on the resident ' s comprehensive care plan.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 16%, or four errors out of 25 opportunities for error.

Inspectors wroteBased on interviews, record review and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure: -Resident food was palatable in taste, texture, appearance and temperature; and, -Meals were served at a palatable temperature.

Inspectors wroteBased on observations and interviews the facility failed to prepare and serve food in a safe and sanitary manner to prevent cross-contamination and potential food borne illnesses, in one of one kitchen during meal services, and one of two dining rooms. Specifically, the facility failed to: -Ensure staff followed accepted hand hygiene practices during the meal service to prevent potential cross-contamination; and, -Ensure resident food was served at the appropriate temperature.

Inspectors wroteBased on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#4) out of five residents reviewed for advanced directives out of 41 sample residents. Specifically, the facility failed to ensure a facility nurse assigned to Resident #4 knew where to locate Resident #4's advance directives to ensure the directives would be carried out in case of emergency. Findings inclue: I. Facility policy The Communication of Code Status policy, revised [DATE], was provided by the facility on [DATE] at 6:47 p.m. The policy read: It is the policy of this facility to adhere to the residents' rights to formulate advanced directives. In accordance to these rights, the facility will Implement procedures to communicate a resident's code status to those individuals who need to know this information. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#25) of 12 residents reviewed out of 41 sample residents was provided personal privacy during care. Specifically, nursing staff failed to ensure they pulled the privacy curtain and keep the door closed while providing incontinence care for Resident #25.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#32 and #56) of eight residents reviewed for accident hazards out of 41 sample residents. Specifically, the facility failed to: -Ensure appropriate and effective measures were in place to prevent Resident #32 from repeated falls, often related to the need to use the restroom. The resident fell eight times between 12/1/22 and 1/23/23. The repeat falls resulting in increased pain for Resident #32; -Ensure fall prevention interventions were put in place after the Resident #56 had an increase in medications that increased the residents risk for falls.; and, -Ensure Resident #56 had walking/locomotion assistance as identified on the resident's minimum data set assessment.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#42) out of one resident who required dialysis care, out of 41 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility: -Failed to blood pressure (BP) measurements were not checked on the right arm where the dialysis fistula/shunt was located; and, -Failed to ensure communication between the dialysis center and the facility.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure one (#42) of 10 residents reviewed for medication administration of 41 sample residents were free from a significant medication error that involved insulin. Specifically, the insulin pen was not primed prior to injection for Resident #42.

Inspectors wroteBased on interviews and record review, the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for nine residents (#37, #42, #305, #15, #34, #6, #18, #47 and #14) out of 24 residents reviewed for narcotic administration out of 33 sample residents. Specifically, the facility failed to ensure narcotic removal documentation in the narcotic log matched the dates of narcotic administration in the resident's electronic medical record (EMR) for Residents #37, #42, #305, #15, #34, #6, #18, #47 and #14.

Inspectors wroteBased on observations, interviews and record review, the facility failed to manage and alleviate pain for one (#37) of five residents reviewed for pain out of 33 sample residents. Resident #37 experienced daily, unrelieved, severe pain described at level 10 on a scale of zero to 10, with 10 being the worst possible pain. Facility assessment on 12/4/21 documented her pain was constant and severe at 8-10 in her back and joints. The pain interfered with her sleep, daily activities and quality of life. The pain evaluation further documented the resident was not satisfied with her pain regime with her pain described as stabbing, aching and shooting spasms. Furthermore, the facility failed to notify the physician of the resident's frequent breakthrough pain, or schedule a pain clinic consultation to find ways to alleviate the resident's pain.