Canyonland Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 5, 2025

  Based on observation, interview, and record review, it was determined that, for 3 of 9 sampled residents, the facility failed to keep residents free from abuse. Specifically, a registered nurse interacted with a resident with unzipped and open pants and touched the resident under the blankets in the abdominal/pelvic area. Additionally, two other residents came forward after the incident with allegations of inappropriate interactions involving the same nurse. Resident identifiers: 1, 2, and 4. It was determined the provider's non-compliance with the requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• Actual harm, isolatedF600Aug 18, 2022

  Based on interview and record review, it was determined that for 1 of 18 sampled residents, the facility did not ensure the resident was free from physical abuse. Specifically, facility staff did not ensure that a resident, known to wander into other residents rooms, was prevented or redirected away from other resident rooms. As a result, another resident, angry by recurring intrusions into his private space, threw a plastic mug striking the uninvited resident on the head, causing a laceration. […]

• No harm, potential for more than minimal, patternF641Aug 18, 2022

  Based on observation, interview, and record review it was determined, for 3 of 18 sample residents, that the facility assessments did not accurately reflect the resident's status. Specifically, a resident who wandered was not coded accurately on the Minimum Data Set (MDS) and was therefore not identified as a wanderer on the care plan. Resident identifiers: 5, 16 and 33. Findings include: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/22 at 11:23 AM, an observation of resident 16 was made. Resident 16 was observed wandering in the hallway. At 11:47 AM, resident 16 wandering into an unsampled resident's room. Resident 16 was observed looking at the decorations for one minute, then exiting the room. […]

• No harm, potential for more than minimal, isolatedF585Nov 5, 2025

  Based on interview and record review, the facility failed to ensure the right to voice grievances to the facility without discrimination or reprisal. Specifically, for 3 out of 18 sampled residents the right to file grievances anonymously was not provided to the residents or representatives of the residents. Resident identifier: 29 [Note: Two resident identifiers were withheld to maintain anonymity.] Findings included: During the survey a confidential interview was conducted with a resident representative, Confidential Interviewee (CI) 1. CI 1 stated that the facility's management did not always address resident, family member, and nursing staff concerns, including the concerns brought up in resident council. […]

• No harm, potential for more than minimal, isolatedF676Nov 5, 2025

  Based on interview and record review it was determined, for 1 of 18 residents sampled, that the facility did not ensure residents were given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. Specifically, a resident was not provided showers. Resident identifier: 3. Findings included: On 11/5/25 resident 3 was interviewed and stated she received hospice care but her showers were provided by the facility. Resident 3 stated she used to receive 3 showers a week but now she had only been getting 2 showers a week. Resident 3 stated she would like to get 3 showers a week and she had told the staff about her concern but nothing had changed. Resident 3's medical record was reviewed 11/3/25 through 11/5/25. […]