Canyon Oaks Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Canyon Oaks Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 26, 2022

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was kept free from neglect. Resident 1, who had verbalized suicidal ideation (thoughts or ideas of killing themselves), and was under strict one-to-one supervision (one staff to remain with the resident at all times); was left unattended by Care Partner 1 (CP1) who was the resident ' s assigned sitter (person assigned to remain with a resident at all times) This deficient practice resulted in Resident 1 obtaining a knife and stabbing himself multiple times in the abdomen , cutting himself in both thighs, and cutting his left arm before being found by another facility staff member. […]

• Immediate jeopardy, isolatedF689Oct 26, 2022

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who had verbalized suicidal ideation (thoughts or ideas of ending one ' s own life), was provided with one-to-one staff supervision as per the psychiatrist (medical doctor who specializes in mental health) order. The one-to-one staff assigned to Resident 1 left the resident unsupervised for five (5) to 10 minutes. This deficient practice resulted in Resident 1 securing a knife and stabbing himself multiple times before being found by another facility staff member. […]

• No harm, potential for more than minimal, widespreadF814May 7, 2026

  Based on observations, interview, and record review, the facility failed to dispose garbage and refuse properly when the dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) surroundings had sticky black spills. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 152 of 152 facility residents. Findings: During a concurrent observation and interview on 5/5/2026 at 8:15 a.m. with the Dietary Supervisor (DS), observed dry and black sticky substance on the grounds in front and to the right of both dumpsters. The left dumpster had black substance dripping from it. […]

• No harm, potential for more than minimal, patternF689May 7, 2026

  Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards for three of seven residents (173, 160, and Resident 2) investigated under the accident care area by failing to: a. Provide upper bed rail padding for a resident with a history of seizures (a sudden surge of abnormal electrical activity in the brain, leading to a range of symptoms like muscle spasms, loss of consciousness) to Resident 173. This deficient practice placed Resident 173 at an increased risk for injuries. b. Ensure that vitamin A&D ointment (a topical skin protectant and moisturizer) and unknown white paste in an unlabeled medicine cup was not left at the Resident 160's bedside. […]

• No harm, potential for more than minimal, patternF755May 7, 2026

  Based on observation, interview, and record review the facility failed to: 1.Administer a form of multiple vitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) to one (1) of six (6) observed residents (Resident 69) during medication administration task, as ordered by Resident 69's physician. 2. Replace one open used medication emergency kit ([ekit] - storage container for emergency use medications) within 72 hours of opening the kit on 4/27/2026, in one (1) of three (3) inspected medication carts (Medication Cart 1 Station 2.) 3. […]