Canyon Springs Post-Acute

In the surveyor’s words

From the most serious findings on record at Canyon Springs Post-Acute, in the surveyor’s own words.

• Actual harm, isolatedF622Jun 14, 2021

  Based on interview and record review, the facility failed to ensure a safe discharge for one of three randomly selected discharged sample residents (Resident 14) when: 1. The facility did not initiate a discharge care plan for Resident 14; 2. The interdisciplinary team (IDT, leaders from different departments discuss the resident's care) did not assess the safety of Resident 14's discharge; Facility discharged Resident 14 to the street and left the resident alone in the street; alone; Facility did not know the Resident 14's whereabouts after the discharge; 3. IDT team members were not involved in the resident's discharge; 4. The facility did not provide Resident 14 the instruction and education for the after discharge care; 5. […]

• No harm, potential for more than minimal, widespreadF880May 9, 2025

  Based on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when: 1. Staff did not use proper gloving technique during a wound dressing change when hand hygiene was not properly performed for Resident 13; 2. Resident 54's urine drainage bag was not covered with a protective bag and was not kept off the floor; 3. Residents' used basins, bed pans and a urinal were unlabeled and stored on top of residents' bathroom toilet tank and under the bathroom sink beside a garbage container; 4. Registered nurse Z (RN Z) used contaminated (something has become impure or unsuitable due to contact with something unclean, harmful, or undesirable) gloves to administer Resident 151's eye drops to both eyes; 5. […]

• No harm, potential for more than minimal, widespreadF880Jun 14, 2021

  Based on observation, interview and record review, the facility failed to maintain proper infection control practices when: 1. Multiple residents did not wear their face masks properly when they were outside the room; 2. Dirty hamper in the hallway was overflowing with linens; 3. Electric fan on top of the Room J has grayish substance inside and out; 4. Residents 51, 61 and 84's oxygen concentrator filters were dusty; 5. There were no documents that indicated multiple residents refused Coronavirus Disease 2019 vaccine (COVID-19, a respiratory disease spreads from person-to-person through respiratory droplets produced when an infected person coughs, sneezes, or talks); 6. Incomplete Visitor Respiratory Screening Questionnaires for COVID-19; 7. […]

• No harm, potential for more than minimal, patternF605May 9, 2025

  Based on interview and record review, the facility failed to ensure three out of 35 sampled residents (Residents 77, 175, and 57) were free from chemical restraints (the use of medications such as psychotropic medications [drugs that affects brain activities associated with mental processes and behaviors, example is antipsychotics, antidepressants, anti-anxiety, hypnotics] not for therapeutic reasons, but to restrict a person's freedom of movement or control their behavior) when: 1. […]

• No harm, potential for more than minimal, patternF641May 9, 2025

  Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated resident assessment tool) assessments for one of 35 sampled residents (Resident 158) when Resident 158's five MDS assessments did not reflect Resident 158's feeding tube (a medical device, a thin and flexible tube, used to deliver nutrition and fluids directly into the digestive system when a person cannot eat or drink safely by mouth) and the percentage of intakes by artificial route. These failures resulted in inaccurate MDS assessments and had the potential to affect the residents' care. […]