Canyonland Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to voice grievances to the facility without discrimination or reprisal. Specifically, for 3 out of 18 sampled residents the right to file grievances anonymously was not provided to the residents or representatives of the residents. Resident identifier: 29 [Note: Two resident identifiers were withheld to maintain anonymity.]

Inspectors wroteBased on interview and record review it was determined, for 1 of 18 residents sampled, that the facility did not ensure residents were given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. Specifically, a resident was not provided showers. Resident identifier: 3.

Inspectors wroteBased on interview and record review, it was determined that for 1 of 18 sampled residents, that the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice. Specifically, the facility did not maintain documentation that a resident's primary care provider had been notified of a resident's change in condition. Resident Identifier: 34 Findings Included: Resident 34 was admitted [DATE], and discharged [DATE] with diagnoses including other frontotemporal neurocognitive disorder, personal history of transient ischemic attack and cerebral infarction without residual deficits, other recurrent depressive disorders, atrioventricular block first degree, age-related osteoporosis without current pathological fracture, hypothyroidism unspecified, essential (primary) hypertension, and hypokalemia. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that for 1 of 18 sampled residents the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise. Specifically, 1 resident experienced significant weight loss with interventions not put into place timely. Resident identifier: 2.

Inspectors wroteBased on observation and interview, it was determined that the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, under proper temperature controls and cautionary instructions, and the expiration date when applicable. Specifically, opened multi-dose pens of medications were not labeled with open dates.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 18 sampled residents, that the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, hospice visit notes were not kept in the residents medical record. Resident identifier: 3.

Inspectors wroteBased on observation, interview, and record review, it was determined that, for 3 of 9 sampled residents, the facility failed to keep residents free from abuse. Specifically, a registered nurse interacted with a resident with unzipped and open pants and touched the resident under the blankets in the abdominal/pelvic area. Additionally, two other residents came forward after the incident with allegations of inappropriate interactions involving the same nurse. Resident identifiers: 1, 2, and 4. It was determined the provider's non-compliance with the requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation, F600, at a scope and severity of J. [...]

Inspectors wroteBased on interview and record review, the facility did not allow the resident the right to formulate an advance directive. Specifically, for 1 out of 15 sampled residents, a resident that did not have a Physician Orders for Life-Sustaining Treatment (POLST) or Advance Directive was documented as do not resuscitate (DNR) in their medical record. Resident identifier: 19.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents were free from abuse. Specifically, for 3 out of 15 sampled residents, allegations of abuse were not investigated to determine if abuse occurred when a staff member reported to management that a residents family member was observed to approach another resident and stand over a resident speaking loudly. In addition, another incident when residents yelled at each other and one resident threw a wet paper towel at another resident were not reported or investigated. Resident identifiers: 20, 22, 23, and 33.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms. Specifically, for 1 out of 15 sampled residents, a Registered Nurse (RN) gave a resident an unprescribed 25 milligram (mg) dose of Trazodone in addition to the resident's prescribed nightly dose of 25 mg of Trazodone. Resident Identifier: 17. Findings Included: Resident 17 was admitted to the facility on [DATE] with diagnoses including aspiration of fluid, respiratory failure, amnesia, nocturia, constipation, and occlusion and stenosis of right posterior cerebral artery. Resident 17's medical record was reviewed from 7/8/24 through 7/11/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately, but not later than two hours after the allegation was made. Specifically, for 3 out of 15 sampled residents, management did not report or investigate when a staff member reported to management that a residents family member was observed to approach another resident and stand over a resident speaking loudly. In addition, another incident when residents yelled at each other and one resident threw a wet paper towel at another resident were not reported or investigated. Resident identifiers: 20, 22, 23, and 33.

Inspectors wroteBased on observation, interview, and record review, the facility did not keep the resident environment as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 15 sampled residents, a resident that choked on their food and required the Heimlich maneuver did not have interventions implemented to prevent future choking. Resident identifier: 31.

Inspectors wroteBased on interview and record review, it was determined that for 1 of 18 sampled residents, the facility did not ensure the resident was free from physical abuse. Specifically, facility staff did not ensure that a resident, known to wander into other residents rooms, was prevented or redirected away from other resident rooms. As a result, another resident, angry by recurring intrusions into his private space, threw a plastic mug striking the uninvited resident on the head, causing a laceration. Resident identifiers: 9 and 27. Cross-refer to F675 regarding noncompliance associated with resident 27's Quality of Life.

Inspectors wroteBased on observation, interview, and record review it was determined, for 3 of 18 sample residents, that the facility assessments did not accurately reflect the resident's status. Specifically, a resident who wandered was not coded accurately on the Minimum Data Set (MDS) and was therefore not identified as a wanderer on the care plan. Resident identifiers: 5, 16 and 33.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 18 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, a resident who wanders did not have a care plan to address wandering. Resident identifiers:

Inspectors wroteBased on observation, interview and medical record review, it was determined, for 2 of 18 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, residents that wandered and took other resident's posessions were not prevented from wandering into other residents' rooms, resulting in those residents' psychological distress. Resident identifiers: 27 and 29.

Inspectors wroteBased on observation, interview and record review, it was determined for 3 of 18 sample residents, that the facility did not ensure that the residents' environment remained as free of accident hazards as possible; and that the residents received adequate supervision and assistance devices to prevent accidents. Specifically, residents were wandering throughout the facility and into other residents' rooms that could pose accident hazards. Wandering residents entered residents' rooms who had threatened them, and supervision was not provided to avoid tripping hazards. Resident identifiers: 9, 16 and 33.