A list of the most recent deficiencies for Canyon Creek 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 that residents are free from significant medication errors. | Health | 2023-09-20 | 2023-10-13 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-07-28 | 2021-08-25 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-07-28 | 2021-08-25 | N |
| Use approved construction type or materials. | Fire Safety | 2021-07-28 | 2021-08-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-07-28 | 2021-08-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-28 | 2021-08-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-28 | 2021-08-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-28 | 2021-08-25 | 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 | 2021-07-23 | 2021-08-16 | 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 | 2021-07-23 | 2021-08-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-23 | 2021-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-23 | 2021-08-16 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-07-23 | 2021-08-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Use approved construction type or materials. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-08-05 | 2020-08-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-27 | 2020-04-08 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-02-27 | 2020-04-08 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-02-27 | 2020-04-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-27 | 2020-04-08 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-02-27 | 2020-04-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-27 | 2020-04-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-27 | 2020-04-08 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-02-27 | 2020-04-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-27 | 2020-04-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-27 | 2020-04-08 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-02-27 | 2020-04-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-26 | 2019-05-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-26 | 2019-05-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-04-26 | 2019-05-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-26 | 2019-05-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-26 | 2019-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-26 | 2019-05-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-26 | 2019-05-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-26 | 2019-05-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-17 | 2019-01-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-17 | 2019-01-21 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-01-17 | 2019-01-21 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-07-28 | Not Fixed | N |
