A list of the most recent deficiencies for Canyon Springs Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-01 | 2023-11-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-03 | 2023-05-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-29 | 2023-04-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-29 | 2023-04-21 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-29 | 2023-04-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-29 | 2023-04-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-07 | 2023-03-18 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-01-27 | 2023-02-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-13 | 2023-02-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-13 | 2023-02-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-13 | 2023-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-13 | 2023-02-02 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-01-06 | 2023-01-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-23 | 2023-01-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-23 | 2023-01-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-23 | 2023-01-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-29 | 2023-01-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-14 | 2022-09-30 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-09-14 | 2022-09-30 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-15 | 2022-03-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-15 | 2022-03-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-15 | 2022-03-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-14 | 2021-07-26 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-06-14 | 2021-07-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-14 | 2021-07-26 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-14 | 2021-07-26 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-06-14 | 2021-07-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-14 | 2021-07-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-06-14 | 2021-07-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-06-14 | 2021-07-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-14 | 2021-07-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-14 | 2021-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-14 | 2021-07-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-06-14 | 2021-07-26 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-06-14 | 2021-07-26 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-06-14 | 2021-07-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-14 | 2021-07-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-14 | 2021-07-26 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-06-14 | 2021-07-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-14 | 2021-07-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-14 | 2021-07-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-06-14 | 2021-07-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-06-14 | 2021-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-14 | 2021-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-14 | 2021-07-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-14 | 2021-07-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-06-16 | 2021-07-15 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-16 | 2021-07-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-16 | 2021-07-15 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-06-16 | 2021-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-16 | 2021-07-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-16 | 2021-07-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-16 | 2021-07-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-06-16 | 2021-07-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-16 | 2021-07-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-16 | 2021-07-15 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-06-16 | 2021-07-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-06-11 | 2019-07-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-11 | 2019-07-02 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-06-11 | 2019-07-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-06-11 | 2019-07-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-11 | 2019-07-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-11 | 2019-07-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-11 | 2019-07-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-11 | 2019-07-02 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-06-11 | 2019-07-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-05 | 2019-05-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-05 | 2019-05-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-05 | 2019-05-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-04-05 | 2019-05-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-04-05 | 2019-05-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-05 | 2019-05-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-05 | 2019-05-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-05 | 2019-05-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-05 | 2019-05-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-04-05 | 2019-05-01 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-04-05 | 2019-05-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-05 | 2019-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-05 | 2019-05-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-04-05 | 2019-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-19 | 2018-05-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-04-19 | 2018-05-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-04-19 | 2018-05-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-04-19 | 2018-05-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-19 | 2018-05-07 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-04-19 | 2018-05-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-19 | 2018-05-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-04-19 | 2018-05-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-03-09 | 2018-04-18 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-03-09 | 2018-04-18 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-03-09 | 2018-04-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-09 | 2018-04-18 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-03-09 | 2018-04-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-09 | 2018-04-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-09 | 2018-04-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-03-09 | 2018-04-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-03-09 | 2018-04-18 | N |
