Inspection Reports for
Canyon View Care Center

The complaint investigation found substantiated physical abuse by Resident #1 against Resident #2 and Resident #3. Both incidents occurred in May and June 2025, with injuries documented and interventions such as 15-minute checks implemented. The facility's investigation confirmed the abuse.

The facility substantiated two incidents of physical abuse by Resident #1 towards Resident #2 and Resident #3, resulting in minor injuries. The facility had existing interventions for Resident #1's aggressive behavior, but no new interventions were implemented after the incidents.

The investigation was complaint-driven based on multiple resident and staff reports of mice sightings and droppings. The complaint was substantiated as mice were found in resident rooms and the kitchen, and the facility's pest control measures were insufficient.

The facility failed to maintain an effective pest control program, resulting in mice infestations in multiple resident rooms and the kitchen. Despite ongoing pest control efforts and audits, mice and mouse droppings were found in various areas, and food storage practices contributed to the problem.

The complaint investigation was substantiated. Resident #1 eloped multiple times, culminating in a 42-hour missing incident causing serious injury. The facility failed to reassess risk, implement interventions, and maintain functioning exit alarms, resulting in immediate jeopardy to resident safety.

The facility failed to reassess Resident #1's elopement risk after multiple elopement attempts and did not implement adequate interventions to prevent further elopements. Emergency exit alarms were not properly armed or responded to, contributing to the resident's elopement and serious harm. The facility's systemic failure created an immediate jeopardy situation that was later removed after corrective actions.

The facility had multiple deficiencies including failure to notify residents about personal funds nearing Medicaid limits, lack of privacy during phone calls, failure to protect a resident from physical abuse, delayed hearing services, inadequate pain management, missing annual staff performance reviews, serving unpalatable and improperly temperature-controlled food, incomplete explanation of binding arbitration agreements, and ineffective infection control program including water management and housekeeping.

The investigation was complaint-related, focusing on the lack of hot water due to the broken hot water heater. The complaint was substantiated with findings of minimal harm or potential for actual harm affecting many residents.

The facility failed to ensure appropriate communication and timely repair of a hot water heater that was over [AGE] years old, resulting in no hot water for approximately three weeks. Residents experienced discomfort and hygiene challenges, and the facility lacked a formal policy for managing such emergencies.

The complaint investigation found substantiated issues related to privacy violations for residents #12, #13, and #18, and failure to prevent elopement of resident #3. The facility's inconsistent supervision and assessment procedures contributed to these deficiencies.

The facility failed to ensure privacy for three residents during care activities and failed to prevent one resident from eloping due to inconsistent supervision procedures. The facility lacked clear protocols for identifying residents needing supervision when leaving the facility, leading to safety risks.

The complaint investigation revealed substantiated issues including failure to provide dignified care, inadequate pain management, poor communication with physicians and MDPOAs, environmental deficiencies, and nutritional neglect. Resident and family interviews corroborated these findings.

The facility failed to ensure residents were treated with dignity and respect, provide timely pain management for severe intractable pain, notify physicians and MDPOAs of critical changes, maintain a clean and homelike environment, and meet residents' nutritional and hydration needs. Multiple residents reported slow call light response, lack of privacy for phone use, and poor food service.

The visit was complaint-related due to resident reports of excessive heat in the facility. Resident council minutes from June 2023 documented concerns about high temperatures. Multiple residents and family members reported rooms reaching temperatures between 80 and 86 degrees Fahrenheit. The complaint was substantiated by observations and temperature measurements during the survey.

The facility failed to maintain comfortable and safe temperatures in resident rooms and hallways across three of four units. Temperatures were frequently measured above 81 degrees Fahrenheit, causing resident discomfort. The cooling system was not functioning at full capacity due to broken swamp coolers and delayed repairs, leading to heat-related issues.

The facility had multiple deficiencies including failure to address resident grievances, inaccurate documentation of advance directives, lack of resident privacy during care, inadequate cleanliness and maintenance of the environment, failure to prevent resident abuse, incomplete PASARR screenings, insufficient fall prevention measures, inadequate nutrition and hydration, medication errors, improper dialysis care, insufficient nursing staffing, and failure to provide palatable and properly served food.

The complaint investigation focused on inadequate pain management for Resident #37 and discrepancies in narcotic medication administration documentation for multiple residents. The complaint was substantiated with findings of failure to manage pain effectively and failure to maintain accurate medication records.

The facility failed to provide adequate pain management for a resident experiencing severe, unrelieved pain and failed to notify the physician or schedule pain clinic consultations. Additionally, the facility failed to maintain accurate narcotic medication administration records, with multiple instances of narcotics removed but not documented as administered.