Indian Canyon Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections, in a universe of 95 residents (Residents 1 to 95), when:1. Laundry Staff 1 (LS 1) and the Housekeeping Lead (HL) did not follow the manufacturer's guidelines for the disinfectant (DS 1) used to disinfect soiled laundry carts and soiled laundry barrels. In addition, the facility staff did not clean and disinfect the clean linen carts located in the resident hallways. This failure had the potential to cause the development and transmission of communicable diseases (an illness or infection that can spread from one person to another, or from a surface to a person) and infections to residents.2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to act promptly upon the resident council's grievances and recommendations when the Grievance Official (GO) failed to address or provide a rationale for the inability to act on the resident council's grievances and recommendations over a three-month period (August 2025 to October 2025) for 16 sampled residents (Residents 1 to 16). This failure had the potential to cause an undermining of residents' independence, a hindering of effective problem resolution and quality improvement, and ultimately creating an atmosphere of fear and distrust within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide interpretive services to residents including Resident 45, whose primary language is other than English. This failure had the potential to compromise residents the ability to understand, comprehend, and effectively communicate their needs, rendering them unable to fully participate in their plan of care, likely leading to residents experiencing diminished self-esteem, social interaction withdrawal, and significant emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan to ensure Resident 89's optimal physical, mental, and psychosocial well-being when Resident 89 displayed a behavior of aggressively chewing on the thumb and first three fingers of the left hand, and the first two fingers of the right hand. This failure resulted in damage to the fingernails on Resident 89's left hand.

Inspectors wroteThe facility failed to ensure that physician's orders were followed for one of one resident (resident 11) reviewed for antibiotic use when the monitoring and documentation of intake and output (I&O) was not done as ordered by the physician. This failure resulted in an incomplete assessment and monitoring of Resident 11's hydration status and fluid balance while on the antibiotic (medication used to treat infections).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 3) reviewed for pressure ulcers (injury to skin and underlying tissues that develops as a result of prolonged pressure, shear, or friction) had a low air loss mattress (LAL mattress - a specialized mattress which is air filled and is designed to help prevent and treat pressure ulcers) which was programmed to Resident 3's weight. This failure resulted in the low air loss mattress to not have the most therapeutic effect for the prevention and treatment of pressure ulcers and for Resident 3 to have increased risk for the development of new pressure ulcers and a delay in wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure controlled substances (a drug or medication whose use is strictly regulated by the government due to its high potential for abuse) were reconciled accurately and in accordance with facility's policy and procedure (P&P), when a licensed nurse signed the facility's narcotics reconciliation log prior to completing the required physical count of the controlled substances. This failure had the potential to result in inaccurate accountability of controlled medications, delayed identification of discrepancies, and risk for medication diversion (the unauthorized use of a medication by someone other than whom it was prescribed for).

Inspectors wroteBased on interview, and record review, the facility failed to provide evidence it received, documented, and acted upon pharmacist recommendations of monthly medication regimen reviews (a pharmacist evaluation of a patient's entire medication regimen with recommendations in order to identify potential problems with ineffective drugs, harmful interactions, incorrect dosages etc.) for one of five residents (Resident 8) reviewed for unnecessary medications. This failure resulted in Resident 8 to be at increased risk for irregularities in the resident's medication regimen to go unidentified and uncorrected which could result in adverse drug effects and avoidable negative outcomes for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 3's antibiotic medication (medication used to treat an infection) was labeled appropriately per facility's policy and procedure (P&P). This failure had the potential to result in administration errors, including administration of the wrong medication, wrong dose, wrong resident, or administration outside the ordered timeframe, thereby affecting Resident 3's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide special eating equipment in the form of an adaptive drinking aid for one sampled resident (Resident 89) when Resident 89, diagnosed with dysphagia (difficulty swallowing), was provided regular standard straws to drink thin fluids instead of a nosey cup (a cup with a U-shaped cutout on one side of the rim, which provides clearance for the nose and allows individuals to drink fluids without tilting their head or neck backward) during his lunch time meal. This failure had the potential to cause Resident 89 to choke, as standard straws deliver liquids quickly and encourage a head-back position that opens the airway. In contrast, the nosey cup encourages a chin-tucked position, reducing the risk of aspiration pneumonia an infection from fluids entering the lungs.

Inspectors wroteBased on interview, and record review, the facility failed to protect against physical abuse for one of three sampled female residents (Resident 1) when a male resident (Resident 2) kissed Resident 1 on the mouth and fondled her (to touch in a sexual way) when Resident 1 did not have the capacity to consent. This failure had the potential to cause Resident 1 to suffer psychological distress, anxiety, and shock.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff administered medication as ordered for 1 (Resident #16) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide facial grooming for 1 (Resident #76) of 2 sampled residents reviewed for activity of daily living (ADL) care.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to transcribe a physician order from an outside ear, nose, and throat (ENT) physician for 1 (Resident #70) of 1 resident reviewed for communication sensory concerns.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan (a document outlining how to best care for a resident and meet their needs) for one of three sampled residents (Resident 3) after Resident 3 suffered a fall with injury. This failure had the potential for Resident 3 to suffer a subsequent fall that could result in another injury or worsening of Resident 3's current injury to his left ribs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the psychosocial wellbeing of 1 out of 3 residents (Resident 1) when the facility put a screw on the window in Resident 1's room to prevent widow from opening all the way. This failure placed resident 1 at risk of depression, and a decline in psychosocial harm when Resident 1 stated he does not feel safe with screw is in the window.

Inspectors wroteBased on interview, observation and record review, the facility failed to remove a building hazard, a threshold (a strip of wood, metal, or stone forming the bottom of a doorway and crossed in entering a house or room) that leads to the patio and is used by residents and families creating a hazard which poses a risk for falls. This failure placed two out of three residents (Resident's 1 and 2) at risk for severe injuries due to falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure a request for documents was fulfilled in a timely manner for two of three sampled residents (Resident 1 and Resident 2) when the facility did not provide the requested documents within the timeframes specified in their policies. This failure had the potential to result in the Resident ' s denial of a timely due process.

Inspectors wroteF642 Based on interview and record review, the facility failed to ensure proper security measures were in place to protect the use of an electronic signature. When (Licensed Vocational Nurse LVN1) used (Registered Nurse RN 1), electronic signature to sign a (Minimum Data Set MDS) verifying the MDS is complete for 66 residents. This failure had the potential to cause inaccuracies in the completed comprehensive assessment in the MDS's for 66 clinically compromise residents. During an interview on October 4, 2023, at 11:22 AM, with the Activities Director, (Activities Director focuses on creating activities that enrich participants' lives with physical and cognitive exercise and socialization through recreational activities such as sports, dancing, arts, and crafts). [...]

Inspectors wroteBased on interviews, and record review, the facility failed to transmit Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) following a significant change in status for 3 out of 22 sampled residents. This had a potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition.

Inspectors wroteBased on interviews, and record review, the facility failed to transmit quarterly Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) within the required quarterly timeframe parameters for 20 out of 22 sampled residents. This had a potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition.

Inspectors wroteBased on interviews, and record review, the facility failed to transmit Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) within the required timeframes for 20 out of 22 sampled residents. This had a potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that a Registered Nurse (RN) was signing, and tracking completed Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) for 20 out of 22 sampled residents. This had the potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing to assure resident safety and the well-being of residents when: 1. A resident (Resident 279) did not receive a PRN (as needed) respiratory treatment in a timely manner. 2. A resident (Resident 17) had to eat in his room instead of the dining room due to not enough staff available to supervise the dining room during mealtimes. 3. A shortage of hours was noted on the Census and Direct Care Service Hours Per Patient Day (DHPPD) on five of six days (December 2, 3, 4, 5, and 6, 2021) reviewed. This failure had the potential to negatively affect the health and safety of medically compromised residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety when: 1. Temperature logs were not updated for four shifts for the refrigerator and freezer. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population in the universe of 70 out of 72 who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 42's right and left hand fingernails were clean and trimmed. This failure has the potential for Resident 42 to experience skin tears and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 18 sampled resident (Resident 46) individual needs and preferences were accommodated when a Resident 46 was not able to reach the pull cord for the overhead light to adjust the lighting according to her needs. This failure led to Resident 46 being dependent on staff and further decreasing her level of independent functioning.

Inspectors wroteBased on interviews, and record review, the facility failed to transmit Minimum Data Set (MDS) assessments (a federally mandated process for assessing resident's functional capabilities and health needs) within the required timeframe parameters for 20 out of 22 sampled residents. This had a potential to cause harm due to missed tracking and trending of changes and/or declines in a resident's condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 18 residents (Resident 10) received needed care and services when Physical Therapist ( PT ) did not follow physician orders for a physical therapy evaluation. This failure had the potential to lead Resident 10 to further decline in physical functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 42 did not develop a reoccurrence of a pressure ulcer (a skin injury caused by pressure) to the right and left heels when facility was not following Resident 42's care plan of applying heel protectors. This failure resulted in Resident 42 developing a reoccurrence of a pressure ulcer to the right and left heels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 42 physician's order were followed when 1. Right and left heel protectors (a device used to prevent skin breakdown) were not applied as ordered by the physician. 2. Left carrot hand splints (a device used to prevent contractures from getting worse) was not applied as ordered by the physician. These failures had the potential to jeopardize Resident 42 health and safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medication was available for administration to a resident (Resident 71) when her 6:00 AM dose of Levothyroxine (Thyroid medication) was not found in the medication cart. This had the potential to cause harmful symptoms such as weight gain, depression, muscle cramps, weakness and memory problems due to low thyroid levels

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medication was disposed of per facility policy when a bottle of medication and a blister pack of pills was found in the medication disposal container in the med room. This had the potential to cause harm due to medication being able to be removed from the waste container and misappropriated.

Inspectors wroteBased on interview, and record review the facility failed to implement an antibiotic stewardship program (an effort to measure and improve how antibiotics are prescribed by physicians and used by patients) when Resident 330 was prescribed antibiotics and there were no criteria used to ensure that they had been prescribed appropriately. This failure had a potential to ineffectively treat infections, protect patients from harm caused by unnecessary antibiotic use and combat antibiotic resistance.