Inspection Reports for
Rock Canyon Respiratory and Rehabilitation Center

The complaint investigation substantiated that Resident #6 physically abused Resident #7 by hitting her after attempting to take her food. The incident was witnessed and confirmed by staff and investigation. Resident #7 had no injuries. The facility took corrective actions including updating Resident #6's care plan.

The facility failed to protect Resident #7 from physical abuse by Resident #6. The investigation confirmed that Resident #6 hit Resident #7 after attempting to take her food. The facility updated Resident #6's care plan to prevent recurrence.

The facility had multiple deficiencies including failure to ensure call lights were within reach for residents, inadequate monitoring of tardive dyskinesia symptoms in a resident on antipsychotic medications, incorrect medication orders and administration, failure to apply prescribed splints for contracture management, medication administration errors related to insulin pen priming, and lapses in infection control practices including housekeeping and glucometer disinfection.

The facility had multiple deficiencies including failure to accommodate residents' needs for call light accessibility, inadequate monitoring of psychotropic medication side effects, medication administration errors, failure to apply prescribed splints for contracture management, and lapses in infection control practices including housekeeping and glucometer disinfection.

The complaint investigation found that Resident #1 was subjected to mental anguish after the NHA arranged a drug purchase involving Resident #1 to identify a drug dealer. Resident #1 reported fear of arrest and discharge, and ongoing distress from the incident. The investigation revealed no documentation of a formal investigation by the facility, and the NHA did not interview other residents or staff beyond those involved.

The facility failed to protect Resident #1 from mental anguish caused by a drug-buying incident orchestrated by the nursing home administrator (NHA). The NHA arranged for Resident #1 to purchase methamphetamines from another resident to identify the drug dealer, which caused Resident #1 fear, discomfort, and ongoing distress.

The facility was found deficient in multiple areas including resident dignity and respect, timely provision of activities of daily living (ADL) care, nutrition and hydration management, tube feeding administration, fall prevention, call light system functionality, and quality assurance program effectiveness. Several residents experienced inadequate care resulting in minimal to actual harm.

The complaint investigation involved allegations that Resident #76 was subject to abuse by an employee through a sexual relationship. The facility's investigation found the relationship occurred but was consensual and did not meet abuse criteria. The employee was terminated for violating the code of conduct. The resident was considered an at-risk adult due to residence in the facility. The investigation included interviews and review of texts and was unsubstantiated for abuse but substantiated for unprofessional conduct.

The facility failed to ensure Resident #76 was free from abuse by an employee, who engaged in an inappropriate relationship with the resident. The employee was suspended and terminated. Additionally, the facility failed to ensure the call light system was fully functional for all 27 residents on the secure unit, including Resident #111, whose call light did not activate notifications and whose care plan lacked appropriate interventions.

The complaint investigation included allegations of environmental deficiencies, abuse by an employee, improper discharge procedures, inadequate dementia care, medication errors, unsanitary kitchen conditions, incomplete medical records, infection control lapses, and non-functional call light systems. The abuse allegation was substantiated with employee termination. The discharge appeal process was not properly followed. Medication errors involved insulin pen priming failures. The call light system was non-functional for some residents.

The facility failed to maintain a clean and safe environment, protect residents from abuse, follow discharge procedures, provide appropriate dementia care, ensure medication safety with insulin administration errors, maintain sanitary kitchen conditions with pest issues, maintain accurate medical records including MOST forms, ensure proper infection control with glucometer disinfection, and provide a fully functional call light system for residents.

The complaint investigation was substantiated with findings that the facility failed to resolve grievances, delayed medication administration, did not ensure residents were transferred out of bed as ordered, failed to provide emergency dental care, inadequately managed pressure injuries leading to infection and hospitalization, and failed to provide appropriate respiratory care including ventilator weaning.

The facility failed to promptly resolve resident grievances, provide timely and appropriate medication administration, ensure residents were transferred out of bed as ordered, provide emergency dental care, prevent worsening of pressure injuries, and deliver respiratory care consistent with professional standards, including proper ventilator weaning.

The complaint investigation was triggered by resident and staff reports of inadequate care, missed showers, delayed call light responses, medication storage concerns, infection control lapses, housekeeping failures, laundry procedure issues, and pest infestations. Resident interviews and observations confirmed these issues. The facility was found to have multiple deficiencies affecting resident care and safety.

The facility failed to provide adequate assistance with activities of daily living including bathing and incontinence care, maintain sufficient nursing staff to meet resident needs, properly store medications, implement effective infection prevention and control measures, maintain housekeeping standards, ensure proper laundry procedures, clean and disinfect reusable medical equipment, and maintain an effective pest control program.

The facility failed to provide personalized activity programs to four residents and did not adequately manage pain for two residents. Observations, record reviews, and interviews revealed minimal engagement in activities and insufficient pain assessment and medication parameters.

The complaint investigation substantiated multiple deficiencies including environmental sanitation issues, failure to protect residents from abuse (sexual and physical), failure to provide adequate personal care, and failure to provide appropriate mental health and dementia care. Immediate jeopardy was identified related to resident abuse but was removed after the facility implemented a plan of correction including 1:1 supervision and staff training.

The facility failed to maintain a safe, clean, and homelike environment, failed to protect residents from abuse including sexual abuse, failed to provide necessary assistance with activities of daily living, and failed to provide appropriate treatment and person-centered care for residents with mental health and dementia diagnoses. Multiple incidents of resident-to-resident abuse and inadequate supervision were documented.