Canyon View Care Center

In the surveyor’s words

From the most serious findings on record at Canyon View Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 15, 2024

  Based on observations, record review, and interviews, the facility failed to ensure that one (#1) of three out of six sample residents was kept safe and free from elopement. Resident #1 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (a chronic, progressive neurological condition) with dyskinesia (involuntary movements). A wander/elopement risk evaluation, completed upon the resident's admission on 8/31/24, revealed Resident #1 had no previous elopement attempts and was not at risk for eloping or wandering. Resident #1's record review revealed the following attempted and successful elopements after admission: On 9/4/24, a progress note revealed Resident #1 left the facility through the South Short Hall emergency exit and was verbally redirected inside. […]

• Actual harm, isolatedF697Aug 24, 2023

  Based on record review and interviews, the facility failed to manage severe intractable pain for one (#3) of 16 sample residents. Resident #3 was admitted to the facility from the hospital on [DATE] with severe pain from cancer that had metastasized to her bones. Resident #3's goal was rehabilitation therapy and strengthening so she could be discharged home with family. Resident #3 had severe pain and physician orders for regularly scheduled and as-needed (PRN) pain medications. However, the resident was only given one dose of PRN pain medication, her daily ordered pain patch was never administered during her stay at the facility, and Resident #3 continued to suffer excruciating pain rated at severe levels, of 8, 9, and 10 out of 10 on ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. […]

• Actual harm, isolatedF600Jan 26, 2023

  Based on record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for seven (#32, #40, #49, #56, #57, #71 and #226) of nine residents reviewed for abuse out of 41 sample residents. Specifically, the facility failed to ensure Resident #32 was free from physical harm and mental anguish. Resident #32 was hit repeatedly in the face by Resident #56 on 12/18/22, resulting in facial lacerations, swelling, and feelings of fearfulness and anxiety. Resident #56 continued to exhibit intimidating behaviors towards that resident in the days following the 12/18/22 altercation. […]

• Actual harm, isolatedF692Jan 26, 2023

  Based on observations, interviews and record review, the facility failed to provide adequate nutrition and hydration to one (#43) of eight residents reviewed out of 41 sample residents. Resident #43 received hospice services and was documented to have unavoidable weight loss. However, the facility failed to assess Resident #43's dietary and drink preferences, assess and implement dietary interventions, provide fortified foods as recommended by the registered dietitian, and provide food and drink access to ensure the resident received the assistance needed for his comfort, enjoyment and dignity, and to ensure he did not go hungry and thirsty. […]

• No harm, potential for more than minimal, widespreadF925Apr 29, 2025

  Based on observations, record review and interviews, the facility failed to maintain an effective pest control program so the environment was free of pests. Specifically, the facility failed to prevent and take adequate measures to eliminate mice within the facility. Findings include: I. Professional references According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (revised 3/16/24) retrieved on 5/1/25, read in pertinent part, The premises shall be maintained free of insects, rodents, and other pests. […]