The Canyons Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedures regarding activities of daily living (ADL) for one of three sampled residents (Resident 1) when Resident 1 did not receive a shower or bath on her scheduled shower day. This failure had the potential for Resident 1 to have body odor, greasy hair, and skin deterioration, which increases the risk of rashes and serious infections, especially for residents who are bedbound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for maintenance service when a sink faucet in room [ROOM NUMBER] was unattached to the sink and without accessible to hot water. This failure resulted in residents and staff to perform handwashing in room [ROOM NUMBER] and had the potential for increased risk of infection for patients and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff implemented appropriate interventions for one (1) of 29 sampled residents (Resident 17) when, nursing staff did not document the restraint (an item used to stop a patient from removing medical equipment or hurting themselves) repositioning every two hours or initiate a restraint care plan as indicated in the facility's policy and procedure (P&P). This failure had the potential to result in resident care needs not being met, inappropriate use of restraints, and failure to identify complications associated with the use of restraints which could jeopardize the health and safety for for Resident 17

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR- federal requirement ensuring that anyone with a serious mental illness, intellectual disability, or a related condition isn't placed in a nursing home without proper assessment and support) was completed for one (1) of 29 residents (Resident 14) when the facility did not complete a required PASRR level 1 screening (a quick check to spot potential mental illness or intellectual disability when someone is about to enter a nursing home) after Resident 14 remained in the facility for more than 30 days under exempted hospital discharge status (EHDS- allows an individual to enter a nursing facility without full PASRR, if a physician certifies before discharge that the resident is likely to need less than 30 days of skilled nursing care). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate catheter care was provided and documented for one (1) of 29 sampled residents (Resident 8) with an indwelling urinary catheter (foley- a tube inserted into the bladder to continuously drain urine) when staff did not document routine cleansing of the foley catheter as required by the facility's policy and procedure (P&P). This failure had the potential to increase the risk for catheter-associated urinary tract infection (CAUTI- a urinary tract infection caused by or associated with urinary catheter), skin irritation, and other catheter-related complications for Resident 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate nutritional interventions and monitoring for 2 (two) of 29 sampled residents (Resident 17 and 104) when: 1. For Resident 17, the facility failed to communicate Registered Dietitian's recommendations to the physician after the Resident 17 experienced weight loss, including recommendations for weekly weights and modification of the tube feeding regimen, resulting in no updated medical orders. 2. For Resident 104, the facility failed to ensure weekly weights were obtained as ordered by the physician. These failures resulted in delayed identification and treatment of nutritional concerns, contributed to continued weight loss, inadequate nutritional intake, and decline in overall health status for Residents 17 and 104.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 29 sampled residents (Resident 29) received enteral feeding (method of delivering liquid nutrition directly into the gastrointestinal tract using a tube placed into the stomach or small intestine) as ordered by the the physician when the ordered daily total of 918 mL (milliliter-unit of measurement ) was not administered. This failure had the potential to result in malnutrition, weight loss, and electrolyte imbalance for Resident 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain effective infection control practices for one (1) of 29 sampled residents (Resident 60) when a humidifier bottle (a device that adds moisture to the air) attached to a tracheostomy (trach- a small tube placed into a surgically created opening in the neck to help a person breathe) oxygen delivery system was observed resting on the floor while in use. This failure resulted in improper handling and positioning of respiratory equipment, which had the potential to introduce germs (tiny organism that can cause an infection) into the humidification system and directly into Resident 60 airway (the breathing passage that carries air from nose and mouth to your lungs), increasing the risk for infections for Resident 60.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately maintain its equipment when:#1. Three (3) of three exhaust fans (removes moisture and odors) in the shower rooms were not operational. This failure had the potential to pose a risk of mold (type of fungus that grows on damp organic matter, appearing as fuzzy, colorful patches and spreading via airborne spores) growth which may compromise the health and well-being of the 124 residents. #2. A faucet in one (1) of five (5) residents' (Resident 1) room was continuously leaking, which is creating a continuous noise disturbance. This failure resulted in disruption for Resident 1, particularly impacting on her ability to fall asleep during the night.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper oral care (refers to the maintenance of a healthy mouth, which includes not only teeth, but the lips, gums, and supporting tissues) was provided for one of three sampled residents (Resident 1) when Resident 1 was found to have larvae (baby form of insects) inside his mouth. This failure could worsen Resident 1's oral health, particularly as he is being treated for periodontitis (bacterial infection that destroys the gums, ligaments, and bone supporting teeth caused by poor oral health and untreated gingivitis)

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices for one of four sampled residents (Resident 1), who was on contact precaution isolation (measures applied when caring for patients with infections known or suspected to spread via touch or contact with contaminated item), when a Certified Nurse Assistant (CNA) failed to wear gloves while picking up the call light of Resident 1 from the floor. This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasites) to Resident 1, other residents, and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of four sampled residents (Residents 1 and 2), when Resident 1's call light was located on the floor, and Resident 2's call light was wrapped around the bed rail. In both instances, the call lights were out of reach of Resident 1 and Resident 2. These failures had the potential to delay Residents 1 and 2's ability to request assistance when needed, increasing the risk of unmet care needs, and possible injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure their Bed-Holds (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) and Returns policy and procedure was implemented for one of four sampled residents (Resident 1) when Resident 1's responsible party (Resident 1's daughter) was not provided any verbal or written information regarding Resident 1's right to exercise the bed hold provision (legal requirement, often lasting 7 days, that allows nursing home or skilled nursing facility (SNF) residents to reserve their specific bed while temporarily hospitalized ) when he was transferred to the general acute care hospital (GACH) on January 4, 2026. This failure resulted in Resident 1 and Resident 1's representative not being able to exercise their right for the bed hold provision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that call light was within reach for two of four sample residents (Resident 1 and 2) reviewed, when Resident 1's call light was observed wrapped around the left bed rail with the cord hanging down towards the floor, while the bedside table was placed against the left bed rail, obstructing access to the call light. Resident 2's call light was observed clipped to the top portion of the bed with the cord oriented away from Resident 2, placing it out of Resident 2's reach. This failure had the potential to delay Resident 1 and 2's ability to request assistance when needed, increasing the risk of unmet care needs, and exacerbating the confusion of Resident 1 and 2, leading to possible Injury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory therapists were available for 41 residents when there was no respiratory therapist on duty for approximately seven (7) hours during the night shift of October 12, 2025. This failure had the potential to place clinically compromised residents' health and safety at risk by not having a respiratory therapist available to provide appropriate care when necessary.

Inspectors wroteBased on interview, and record review, the facility failed to ensure appropriate dialysis (the process of removing excess water and cleaning the blood) treatment was acquired for one of three residents (Resident 1) for 2 days. This failure resulted in a clinically compromised resident Resident 1 not receiving dialysis as ordered by the physician and was sent out to acute hospital for treatment and placing health and safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy in providing Activities of Daily Living (ADLS) when showers/bed bath were not provide as scheduled for 17 of 25 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12,13,14,15,16, and 17). This failure had the potential to result in skin irritation, odor, and decreased quality of life for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Certified Nursing Assistant (CNA) performed hand hygiene after doffing (removing) Personal Protective Equipment (PPE) upon leaving the isolation (to keep patients with contagious diseases separate from others) room for two of 25 (Resident 18 and 19). This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasites) to other residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform timely maintenance on the ventilators (a breathing machine or breathing device that helps a resident breath when they cannot do it on their own) for two (2) of five (5) sampled residents (Residents 1 & 2). This failure has the potential to cause malfunctions of the ventilators, which may place the health of clinically compromised Residents 1 and 2 at risk.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its Activities of Daily Living ADLs policy and procedure for 3 of 3 sampled Residents (Resident ' s 1,2 and 3) when: Resident ' s 1, 2 and 3 were left soiled and wet on observation April 30, 2025. This failure had the potential to cause (Resident 1,2, and 3) health and safety to be at risk for skin breakdown when their care needs were not met.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure an admission Minimum Data Set (MDS) assessment was completed no more than 13 days after the admission date for 1 (Resident #333) of 27 sampled residents for whom MDS assessments were reviewed.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment accurately reflected the location to which a resident was discharged for 1 (Resident #128) of 27 sampled residents for whom MDS assessments were reviewed.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #104) of 6 sampled residents reviewed for unnecessary medications was monitored for the presence of adverse drug reactions or other side effects related to the use of a prescribed antipsychotic medication.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure nursing staff cleaned and disinfected supplies between resident uses for 2 (Resident #72 and Resident #38) of 7 residents observed during medication administration observations.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its Activities of Daily Living ADLs policy and procedure for 3 of 4 sampled Residents (Resident's 1,2 and 3) when: 1. Resident 1 used call light to get staff attention for help, waiting over an hour. 2. Resident 2 used call light to get assistance, then is turned off by staff failing to return or returning after an hour wait. 3. Resident 3 used call light along with roommates to help get assistance, staff states I'm not the assigned staff will look for assigned staff, this prolonged already long wait times. This failure had the potential to cause (Resident 1,2, and 3) health and safety to be at risk for skin break down when their care needs were not met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and homelike environment, when the shower room used by two of three sample residents (Resident 1 and 2) had uneven flooring, fractured tiles, and permanent residue on the wall. This failure had the potential to affect the health and wellness of Resident 1 and 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to its safety and supervision of resident ' s policy when one of the four sampled residents (Resident 1) was left unattended during patient care. This failure had the potential to put a clinically compromised resident (Resident 1) at risk for serious injury, resulting in Resident 1 falling and requiring transfer to an acute general hospital for evaluation and treatment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for all three sampled residents (Residents 1, 2, and 3). This failure has the potential to jeopardize the health and safety of three clinically compromised Residents (Residents 1, 2, and 3) when their requests for assistance with activities of daily living were not responded to promptly.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure 1 of 3 sampled residents (Resident 1), was provided proper wound care treatments and assessment. This failure placed a clinically compromised Resident (Resident 1) health and safety at risk. When skin integrity was not being treated and assessed by nursing staff that resulted in infection and hospital stay.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect for one of three residents (Resident 1), when the Registered Nurses failed to perform a comprehensive nursing assessment (a detailed physical examination of the patient's entire body, to gather information about the patient's status) on Resident 1 upon his initial admission to the facility on July 3, 2024, and his readmission from the hospital on July 9, 2024,after Resident 1 was sent out due to being unresponsive. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure licensed nurses were provided training to demonstrate competencies with paracentesis drainage tube (a catheter to remove fluid from the abdominal cavity) and gastrostomy tube feeding (G-tube, a tube inserted through the abdominal wall that brings nutrition directly to the stomach), for one of three residents (Resident 1) when Registered Nurse 6 (RN 6) connected and infused the enteral feeding formula (liquid food designed to provide nutrition directly into the stomach) to the paracentesis drainage tube, instead of the gastrostomy tube feeding, on July 9, 2024. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights were answered in a timely manner for two out of four sampled residents (Residents 1 and 2). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Resident 1 & Resident 2) when their requests for assistance with activities of daily living were not responded to promptly.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow its policy and procedure for prevention of pressure ulcers/injuries when one of four sampled residents (Resident 1) was not repositioned in a timely manner. This failure resulted in the development of pressure ulcer of clinically compromised resident (Resident 1).

Inspectors wroteBased on observation, interview, and record review the facility failed to follow Its policy and procedure to provide Activities of Daily Living Services (ADLS) and ensure call lights are answered in timely manner for two of three sampled residents. (Resident's 2 and 3). This failure had the potential to place clinically compromised Residents (Resident 2 and 3) health and safety at risk. When residents were left soiled, and their hygiene needs were not met.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its policy and procedure to provide activities of daily living services (ADLS) and ensure two of three residents (Resident 1 and Resident 2) received care with changing when needed. This failure had the potential to place two clinically compromised Residents (Resident 1 and 2) health and safety at risk. When residents were left soiled, and their hygiene needs were not met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their abuse policy and procedure was implemented, when a Licensed Vocational Nurse (LVN 2) and a Registered Nurse (RN) did not report an allegation of rape to the Administrator and Director of Nursing (DON) immediately, for one of three sampled residents (Resident 1), on December 24, 2023. This failure had the potential for Resident 1 to experience psychosocial harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that an injury of unknown origin was promptly reported to the California Department of Public Health (CDPH) in accordance with the facility's policy, for one of three residents (Resident 1). This failure had the potential for an injury of unknown origin to go uninvestigated and unreported thereby increasing the chances of harm to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to prevent an elopement (unsupervised wandering that leads to the resident leaving the facility) by Resident 1 when he left the facility unnoticed and was found unsupervised in the parking lot. This failure resulted in a mentally compromised resident (Resident 1) sustaining a fall with injuries and placed this residents' safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to update a comprehensive care plan for one of three Residents (Resident 1). This failure contributed to the decline and development of Resident 1 ' s pressure ulcers.

Inspectors wroteBased an interview, and record review, the facility failed to ensure a one of three residents (Resident 1) did not develop a pressure ulcer when staff did not reposition and turn Resident 1 frequently or every two hours as per their policy. This failure contributed to the development of a pressure ulcer to Resident 1 ' s sacrum (bone located on the bottom of the spine).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their infection control program was followed when: 1. Three dialysis caregivers (Caregiver 1, 2 and 3) from [Name of dialysis center] accessed the Central Venous Catheter (CVC, a flexible thin tube that is inserted to the vein to the large artery of the heart used for hemodialysis, (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys no longer work, a life sustaining procedure) and practiced poor infection control for two of three (Residents 216, and 220) of 3 hemodialysis sampled residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a sanitary kitchen environment when: 1. The walk-in freezer that provided storage of food for 83 out of 120 residents, had a red colored dry spillage and crumbs under where the meat and chicken trays were stored. This had the potential for microorganism (small organisms which have the potential to cause disease) growth and to attract pests. 2. The floor under the oven and stove had food crumbs, trash and grime, and there were streaks of residue and grime on the sides of the oven and stove. This had the potential to promote bacterial growth within this area as well as attract microorganisms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect when one of three sampled residents (Resident 420) pressed the call light for help because she felt like she could not breathe, and waited 20 minutes for assistance, despite multiple staff members passing her room as the resident loudly pleaded for help. This failure had the potential to cause Resident 420's needs go unmet, resulting in fear, anxiety, and frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents could exercise their rights within the facility when one of three sampled residetns (Resident 83) requested for her foley catheter (a flexible tube used to drain urine) to be discontinued but was not carried out as ordered by the attending physician. This failure had the potential for a negative psychosocial outcome for one of three sampled residents (Resident 83) related to her right to make decisions about her care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and document resident's current health status for the use of an anticoagulant (blood thinner) during Minimum Data Set (MDS, (a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status), assessment. This failure had the potential for care and services to remain unmet for one (Resident 10) of six sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oversight and ensure that only Dialysis (a life sustaining procedure of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions naturally) Registered Nurses were allowed to access residents' central venous catheters (CVC), (CVC- a plastic flexible tube that's located in the neck, upper chest, or groin. The CVC is connected to the bloodlines during dialysis, allowing for the transfer of blood to and from the body to the dialysis machine and back) during the provision of resident's dialysis care, according to professional standards of practices when: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were safely prepared for six out of six residents (Resident 418, 115, 416, 417, 420, and 69) when one Licensed Vocation Nurse (LVN 1) prepared medications for the six residents at the same time and more than three hours in advance of when the medications were ordered for administration. This failure had the potential for these vulnerable residents to receive the wrong medications, which could lead to adverse health outcomes and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medications were secured, when one (med cart 1) of four medication carts (used to transport resident medications) were found unlocked and unattended by a licensed nurse, with the keys to unlock the narcotics (prescription pain medications) drawer placed on top of the medication cart. This failure had the potential to compromise the security of the medications and potentially allow unauthorized staff and residents to access these medications.