Canyon Vista Post Acute

Inspectors wroteBased on observation, interview record review and document review, the facility failed to ensure:1) medications were not left on a resident's breakfast tray and documented as administered without direct observation of ingestion for 1 of 40 sampled residents (Resident 96);2) medications were not pre-charted as administered prior to actual administration for 1 of 40 sampled residents (Resident 153); and3) nephrostomy care was not documented as completed without actual provision of care for 1 of 40 sampled residents (Resident 77). The deficient practice had the potential to compromise quality of care provided to residents.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure care orders for nephrostomy tubes were followed for 1 of 40 sampled residents (Resident 77). The deficient practice placed the resident at risk for infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items were not expired, properly dated, labeled, and discarded as required from the refrigerator for 3 of 4 nourishment rooms inspected. This deficient practice had the potential to result in foodborne illness, affecting the health and safety of residents.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the trash compactor was sealed, in good repair, and free of leaks, foul odors, and accumulated liquid waste. The deficient practice created the potential for unsanitary conditions, foul odors and pest infestation.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was available in the laundry room for staff handling soiled linens. This deficient practice had the potential to expose staff and residents to contaminants from soiled linens and increased the risk of transmission of infectious organisms in a facility with active resident infections.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Release of Information policy included a defined time frame for providing resident medical records when requested. The deficient practice had the potential to delay access to a resident's medical records.

Inspectors wroteBased on observation, interviews, record review, and documentation review, the facility failed to ensure a copy of the discharge medication list and education about the medication was provided for 1 of 6 sampled residents (Resident 5). This failure had the potential to lead to medication errors and adverse drug reactions causing resident harm.

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure three of three residents sampled for accidents (Resident 14, 34, and 116) had interventions implemented to identify hazards and risks associated with smoking. The facility failed to ensure: 1) Resident 14 with a lighter and cigarettes did not attempt to put a used cigarette in a trash can within the resident's room, 2) Resident 34 was a documented smoker with an Oxygen Concentrator (a device delivering up to 95 percent Oxygen, Oxygen when in contact with flammable materials through heat can cause severe burns) in the resident's room, and 3) a non-smoking policy and procedure was enforced when Resident 116 (R116) took out a black lighter from the left chest pocket. The deficient practice had the potential to result in fire hazards and compromise the safety of all residents and staff in the facility. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure that opened items in the refrigerator and freezer were properly labeled and discarded upon expiration per policy. This deficient practice had the potential to result in the serving of expired or improperly stored food items to residents, potentially leading to foodborne illness.

Inspectors wroteBased on interview, record review and document review, the facility failed to develop and implement baseline care plan for: 1) safety interventions for the care of 4 of 5 residents who smoke (Residents # 188, 189, 190, and 320), 2) interventions to address communication issues for 2 resident with communication deficit related to language barrier (Resident #171 and 324), and 3) interventions for the care of a peripheral intravenous (IV) catheter (Resident #325).

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to develop comprehensive care plans to reflect new interventions, specifically, a smoking care plan for 3 of 3 sampled residents (Residents 14, 34, and 116). The deficient practice had the potential to deprive residents of necessary interventions to maintain overall well-being.

Inspectors wroteBased on observation, record review, document review, and interview, the facility failed to respond to resident call lights in a timely manner for 1 of 41 sampled residents (Resident 17), and 2 unsampled residents. The failed practice had the potential to cause delay in resident care and needs.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the Foley catheter was properly assessed and the correct Foley size was inserted or clarified and appropriately documented in the medical record for 1 of 41 sampled residents (Resident 104). This deficient practice had the potential to result in complications such as discomfort, urinary tract injury, bladder trauma, or obstruction.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a nephrostomy tube (a tube inserted directly into the kidney to drain urine) insertion site care was documented in the medical record for 1 of 9 sampled residents (Resident 1). The deficient practice made it uncertain if site care including periodic cleaning and application of a dressing had been provided; and could have contributed to infections in R1's skin and tissue adjacent to both nephrostomy tube insertion sites.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure that an impaired nutrition assessment or a comprehensive nutritional assessment was completed upon admission and failed to address the resident's severe weight loss (over 5 percent) with interventions for undesirable weight loss for 1 of 41 sampled residents (Resident 121). The deficient practice had the potential to result in continued weight loss and malnutrition, impacting Resident 121's overall health and well-being.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the tube feeding order was followed, the actual total dose volume consumed was monitored, and the daily enteral feed and caloric intake were documented for 1 of 41 sampled residents (Resident 271). This deficient practice could have the potential to result in inadequate nutrition, dehydration, weight loss, and improper tube feeding administration.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to obtain a physician's order for the use of an intravenous (IV) access or heplock, including assess and monitor the site, identify whether an IV was present upon admission, and document for 2 of 32 sampled residents (Residents 104 and 325). This deficient practice had the potential to cause complications such as infection, infiltration, phlebitis, or impaired venous access.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the resident's pain was consistently assessed or reassessed, managed, and documented in a timely manner in the Medication Administration Record (MAR) for 2 of 41 sampled residents (Residents 273 and 17). This deficient practice could have the potential for unrelieved pain, discomfort, and inadequate pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% during medication pass. There were 25 opportunities observed, which revealed two errors. The medication error rate was 8%.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a safe and functional environment was provided for residents in the 200 hall by not maintaining a functioning call light system. The failed practice placed the residents at risk of not having call lights answered in a timely manner, delayed response to resident's needs and increased accidents risk.

Inspectors wroteBased on interview, and document review, the facility failed to document a response to concerns raised by the Resident Council group, and report actions taken and their rationale to the Resident Council. The deficient practice had the potential to adversely affect resident quality of life.

Inspectors wroteBased on observation, interview, and document review, the facility failed to label and date food items and maintain clean floors. The deficient practice posed a potential risk to safety and health standards as it could lead to contamination, inadequate storage, or place the residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a resident's request for a change in shower schedule was honored for 1 of 24 sampled residents (Resident 3). The deficient practice deprived the resident of the right to self-determination.

Inspectors wroteBased on observation, interview, record review and document review the facility lacked documented evidence a respiratory therapeutic device was consistently monitored and cared for per physician order for 1 of 24 sampled Residents (Resident 221). The deficient practice had the potential for a resident's therapeutic drain's output to be routinely monitored and recorded.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure resident specific medication was labeled accordingly with resident's name and vial open date for 1 of 4 medication rooms. The deficient practice could result with cross contamination of resident medication and administration of a sub-potent medication.