Rock Canyon Respiratory and Rehabilitation Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#7) of eight residents reviewed for abuse out of 13 sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #7 from physical abuse by Resident #6.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of four units. Specifically, the facility failed to: -Ensure housekeeping staff followed the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas; -Ensure housekeeping staff followed the appropriate procedure when cleaning resident bathrooms; -Ensure housekeeping staff were trained appropriately on housekeeping procedures; -Ensure housekeeping staff performed appropriate hand hygiene; and, -Ensure individual glucometers were cleaned properly.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide reasonable accommodation necessary to accommodate mobility and accessibility in the residents' environment for two (#119 and #120) of seven residents reviewed out of 43 sample residents. Specifically, the facility failed to ensure Resident #119 and Resident #120's call lights were within reach when the residents were in bed.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from chemical restraints for one (#122) of five residents out of 43 sample residents. Specifically, the facility failed to ensure Resident #122, who was on antipsychotic medication, received appropriate monitoring to ensure signs and symptoms of tardive dyskinesia (involuntary movements) did not worsen.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#53) of five residents out of 43 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to ensure the physician's orders for Resident #53 contained the appropriate dose of the medication that was to be administered to the resident.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion (ROM) and/or prevent further decrease in ROM for one (#33) of three residents reviewed for restorative services out of 43 sample residents. Specifically, the facility failed to ensure Resident #33's bilateral hand contracture soft splints were applied for contracture management per physician's order.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#15) of six residents reviewed for medication errors of 43 sample residents. Specifically, the facility failed to ensure that Resident #15 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of one resident was free from mental anguish out of three sample residents. Resident #1 was admitted to the facility on [DATE] for long term care with a diagnosis of diagnoses included developmental disabilities, dementia, depression, anxiety, schizophrenia (mental illness), myocardial infarction (heart attack), nicotine dependence, hypertension (high blood pressure), coronary heart disease and chronic obstructive pulmonary (lung) disease (COPD). On 12/7/24, the facility staff noticed Resident #1 had a pipe used to smoke methamphetamines. The nursing home administrator (NHA) approached Resident #1 in order to find out where the resident was purchasing the drugs. The NHA asked Resident #1 if he could observe the resident purchase drugs to determine who was selling the drugs within the facility. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible for one (#20) of four residents reviewed for accident hazards out of 29 sample residents. Resident #20, who had severely impaired daily decision-making skills, was admitted on [DATE]. The facility determined the resident to be at risk for falls upon her admission and implemented a care plan with generalized fall risk interventions that were not individualized for Resident #20. Resident #20 sustained falls with minor injuries on 5/3/24, 5/10/24 and 5/16/24. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#23 and #1) of nine residents reviewed for weight loss out of 29 sample residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being Resident #23, admitted at nutritional risk and lost 14 pounds in six weeks. While nutritional interventions were initiated on admission (supplements three times a day) and again when a significant weight loss was identified on 6/20/24 (fortified foods), observations revealed the facility failed to promote the resident's nutritional status by encouraging, cueing and assisting the resident at mealtime, documenting his intake of snack and supplement, and addressing his agitation in the dining room at mealtime. No new interventions were considered when the resident continued to lose weight. [...]

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure residents with percutaneous endoscopic gastrostomy (PEG) tubes received treatment and services to prevent complications for eight (#10, #25, #13, #15, #12, #14, #16 and #11) of nine residents reviewed for tube feeding management out of 29 sample residents. Specifically, the facility failed to: -Label Resident #10, Resident #25, Resident #13, Resident #15, Resident #12, Resident #14, Resident #16 and Resident #11's tube feeding containers with the residents' names, room number, date, start time, formula type, feeding rate and nurse initials; -Provide Residents #10, Resident #12, Resident #14, Resident #15, Resident #16 and Resident #25, with the prescribed formula as written in the computerized physician orders (CPO); [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life and quality of care.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for six (#10, #16, #14, #6, #24 and #9) of 13 residents reviewed for ADLs out of 29 sample residents. Specifically, the facility failed to: -Ensure Resident #10, #16 and #14 received timely repositioning and toileting/incontinence care while in bed; -Ensure Resident #6 and #24 received timely repositioning and toileting/incontinence care; and, -Ensure Resident #9 received assistance with meals.

Inspectors wroteBased on observations, record review and interviews the facility failed to adequately equip the residents to call for staff for two (#8 and #24) of three residents out of 29 sample residents and to provide a working call light system in the shower facilities. Specifically, the facility failed to: -Provide a working call light for Resident #24 and Resident #8; and, -Have a functioning call light system in the women's and men's shower areas.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for two (#16 and #28) of two residents reviewed for respect and dignity out of 29 sample residents. Specifically, the facility failed to: -Ensure Resident #16 had privacy when he slept in a brief; and, -Ensure Resident #28 was dressed appropriately and not exposed in the dining room.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a clean, comfortable and homelike environment for 27 of 27 residents in two of two hallways on the secure unit and one of eight residents reviewed on the rehabiliation unit. Specifically, the facility failed to: -Ensure resident rooms were in good repair, blinds were maintained and doors in good condition; -Ensure common areas and the dining room such as walls and baseboards were cleaned and maintained in good repair in the secure unit; -Ensure resident rooms and closet space was labeled appropriately; and, -Ensure resident common area furniture was in good condition.

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare and serve food in a sanitary manner in one of two kitchens. Specifically, the facility failed to ensure dish room sanitation was maintained to eliminate harborage conditions for pests in the secure unit kitchen.

Inspectors wroteBased on record review and interviews, the facility failed to maintain medical records on each resident that were accurately documented for three (#3, #22 and #59) out of four residents reviewed out of 47 sample residents. Specifically, the facility failed to: -Ensure the medical orders for scope of treatment (MOST) form had complete and accurate documentation of who obtained verbal consent from legal decision makers; and, -Ensure timely follow up was completed with a signature from the resident's legal representative.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to ensure the call light system was functioning properly in its entirety. Specifically, the facility failed to ensure all 27 residents on the secure unit had access to a functioning call light system.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure the residents were free from abuse for one (#76) of three residents reviewed for abuse out of 47 sample residents. Specifically, the facility failed to ensure Resident #76 was safe from abuse by an employee.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a facility initiated discharge procedure was followed for one (#76) of two residents reviewed for discharge out of 47 sample residents. Specifically, the facility failed to follow the appropriate procedure for Resident #76's facility initiated discharge from the facility when he requested an appeal.

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 one (#70) of two residents reviewed for dementia care out of 47 sample residents. Specifically, the facility failed to: -Implement wandering interventions as listed on the care plan for Resident #70; and, -Consistently document Resident #70's wandering behavior and interventions used to determine the effectiveness of the interventions.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure the medication error rate was not greater than five percent. Specifically, the facility's medication error rate was 6.25% with two errors out of 31 opportunities.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for two (#53 and #73) of six residents reviewed for medication errors of 47 sample residents. Specifically, the facility failed to ensure that Resident #53 and Resident #73 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection in one out of two units. Specifically, the facility failed to ensure a glucometer was cleaned in a sanitary manner.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for for one (#1) of three residents reviewed for dental care out of five sample residents. The facility failed to provide emergency dental services for Resident #1. Resident #1's family was visiting on 4/16/23. The family notified the licensed nurse on duty of a broken, dark tooth, pain, discoloration and swelling to the resident's right lower jaw and neck. The family member said it was weeks before he was seen by a dentist, and the facility just kept giving him antibiotics. The resident received oral and intravenous (IV) antibiotics between 4/18/23 and 5/25/23 for repeat swelling and pain to the jaw. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent worsening and infection of a pressure injury for two (#1 and #3) of four residents with pressure injuries out of five sample residents. Resident #1 admitted to the facility on [DATE] with intact skin. Resident #1 developed pressure injuries at the facility to his sacrum, left shoulder and right buttock. He had multiple comorbidities including a history of cardiogenic shock (heart not pumping enough blood to organs) and chronic respiratory failure, rhabdomyolysis (muscle tissue breakdown) and diabetes mellitus. He was at high risk for pressure injuries. The facility failed to initiate treatment when the sacral wound was first found on [DATE] for three days until [DATE]. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#5) of three residents reviewed out of five sample residents received respiratory care consistent with professional standards of practice. Resident #5 was admitted to the hospital from home on 6/28/23 with pneumonia. While at the hospital a tracheostomy was placed and the resident was placed on a mechanical ventilator (machine that breathes for you, ensures large enough breaths are taken). During the last week of the resident's hospitalization he was weaned from a ventilator down to a bi-level positive airway pressure (BIPAP, helps keep the airway open with positive pressure and gives more oxygen to the lungs, a person breathes on their own). The facility admitted the resident on 8/4/23. The facility placed him back on a mechanical ventilator. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents and or there representatives were provided prompt efforts by the facility to resolve grievances for one (#5) of three residents reviewed out of five sample residents. Specifically, the facility failed to address, resolve, document and follow up on grievances expressed by Resident #5 and the resident representative on 8/31/23 during a care conference.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide services for one (#5) out of three residents reviewed out of five sample residents according to professional standards of practice. Specifically, the facility left medications at Resident #5's bedside, who could not physically self administer medications.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain mobility for two (#3 and #5) of three residents reviewed out of five sample residents. Specifically, the facility failed to ensure Resident #3 and Resident #5 were transferred out of bed according to their preference, orders and plan of care.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to create an environment that protected two (#37 and #124) of six residents reviewed for abuse out of 38 sample residents. Resident #69, with moderate cognitive impairment, exhibited inappropriate sexual behavior toward one resident (#37) who had severe cognitive impairment. Resident #37 was sexually abused on 8/6/22 by Resident #69. In response to the 8/6/22 incident, the facility temporarily moved Resident #69 to another unit and provided one-on-one staff supervision for six days. Resident #69 returned to his original unit and 15 minute checks were instituted from 8/13/22 to 8/19/22. Supervision was changed to 30 minute checks between 8/20/22 and 8/31/22. [...]

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for resident rooms and on two of six hallways. Specifically, the facility failed: -To ensure walls, ceilings, doors, and floors were repaired, painted and properly maintained; and, -To ensure water temperatures were maintained at safe and comfortable temperatures.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who displayed or was 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 two (#69 and #73) of three residents reviewed for dementia care out of 38 sample residents. Specifically, the facility failed: -To provide person-centered approaches to Resident #69's dementia care services to address his sexual behaviors towards staff and other residents in order to prevent sexual abuse incidents on the secured unit; and, -To effectively identify person-centered approaches for dementia care and wandering for Resident #73.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services and assistance during showers and baths for one (#82) of three residents reviewed for hygiene assistance of 38 sample residents. Specifically, the facility failed to provide scheduled showers and baths or offer an alternative for Resident #82.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that a resident who displayed or was diagnosed with mental disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for two (#82 and #60) of three residents out of 38 sample residents. Specifically, the facility: -Failed to address Resident #60's ongoing depression. -Failed to develop person-centered individualized interventions for verbal aggression and non-compliance for Resident #82; -Failed to track aggression and non-compliance behaviors to help drive person-centered interventions and evaluate efficacy of said interventions for Resident #82; and, -Failed to train staff on person-centered individualized interventions for Resident #82.