Rock Canyon Respiratory and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 15, 2022

  Based on record review, observations, and interviews, the facility failed to create an environment that protected two (#37 and #124) of six residents reviewed for abuse out of 38 sample residents. Resident #69, with moderate cognitive impairment, exhibited inappropriate sexual behavior toward one resident (#37) who had severe cognitive impairment. Resident #37 was sexually abused on 8/6/22 by Resident #69. In response to the 8/6/22 incident, the facility temporarily moved Resident #69 to another unit and provided one-on-one staff supervision for six days. Resident #69 returned to his original unit and 15 minute checks were instituted from 8/13/22 to 8/19/22. Supervision was changed to 30 minute checks between 8/20/22 and 8/31/22. […]

• Actual harm, isolatedF600Apr 3, 2025

  Based on record review and interviews, the facility failed to ensure one (#1) of one resident was free from mental anguish out of three sample residents. Resident #1 was admitted to the facility on [DATE] for long term care with a diagnosis of diagnoses included developmental disabilities, dementia, depression, anxiety, schizophrenia (mental illness), myocardial infarction (heart attack), nicotine dependence, hypertension (high blood pressure), coronary heart disease and chronic obstructive pulmonary (lung) disease (COPD). On 12/7/24, the facility staff noticed Resident #1 had a pipe used to smoke methamphetamines. The nursing home administrator (NHA) approached Resident #1 in order to find out where the resident was purchasing the drugs. […]

• Actual harm, isolatedF689Jul 12, 2024

  Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible for one (#20) of four residents reviewed for accident hazards out of 29 sample residents. Resident #20, who had severely impaired daily decision-making skills, was admitted on [DATE]. The facility determined the resident to be at risk for falls upon her admission and implemented a care plan with generalized fall risk interventions that were not individualized for Resident #20. Resident #20 sustained falls with minor injuries on 5/3/24, 5/10/24 and 5/16/24. […]

• Actual harm, isolatedF692Jul 12, 2024

  Based on record review and interviews, the facility failed to ensure two (#23 and #1) of nine residents reviewed for weight loss out of 29 sample residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being Resident #23, admitted at nutritional risk and lost 14 pounds in six weeks. While nutritional interventions were initiated on admission (supplements three times a day) and again when a significant weight loss was identified on 6/20/24 (fortified foods), observations revealed the facility failed to promote the resident's nutritional status by encouraging, cueing and assisting the resident at mealtime, documenting his intake of snack and supplement, and addressing his agitation in the dining room… […]

• Actual harm, isolatedF684Sep 11, 2023

  Based on interviews and record review, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for for one (#1) of three residents reviewed for dental care out of five sample residents. The facility failed to provide emergency dental services for Resident #1. Resident #1's family was visiting on 4/16/23. The family notified the licensed nurse on duty of a broken, dark tooth, pain, discoloration and swelling to the resident's right lower jaw and neck.The family member said it was weeks before he was seen by a dentist, and the facility just kept giving him antibiotics. […]