Canon Lodge Care Center

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

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.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Smoke Deficiencies

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Provide properly protected cooking facilities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Pharmacy Service Deficiencies

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.

A licensure survey prompted by complaint #CO38702 was completed on 12/2/24 to 12/4/24. One deficiency was cited. Based on record review and interviews, the facility failed to ensure qualified social services staff was employed to meet the social and emotional needs of the residents.Specifically, the facility failed to employ a qualified social worker. Findings include:I. Staff interviewsThe social service director (SSD) was interviewed on 12/4/24 at approximately 11:30 a.m. The SSD said she had recently started working at the facility in February 2024. She said she was not a licensed social worker and did not have a college degree. She said she did not have a social work consultant who worked with her at the facility. The nursing home administrator (NHA) was interviewed on 12/5/24 at 5:20 p.m. The NHA said she was newly hired at the facility. She said she was not aware the SSD was not a qualified social worker. She said she was aware of the state regulation which required the social services department to have a qualified social worker with a degree in social work or a closely related field. The NHA said the regional vice president (RVP) was contacting social work consultants (during the survey).

A survey prompted by #CO35472, #CO37019 and #CO38263 was conducted on 12/2/24 to 12/4/24. Five deficiencies were cited. Based on interviews and record reviews, the facility failed to ensure an effective discharge planning process for three (#8, #6 and #7) out of four residents reviewed out of 14 sample residents. Specifically, the facility failed to:-Ensure the discharge planning process was documented in Resident #8, Resident #6 and Resident #7' s medical record; and, -Ensure the interdisciplinary team was involved in the discharge planning process for Resident #8, Resident #6 and Resident #7.Findings include:I. Resident #8A. Resident statusResident #8, age 76, was admitted on 5/30/24 and discharged home on 9/4/24. According to the September 2024 CPO diagnoses included retention of urine, hypertensi.. Based on observations, record review and interviews, the facility failed to ensure that residents requiring treatments and services for mental disorders or psychosocial adjustment difficulties received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well being for two (#2 and #4) of four residents reviewed out of 14 sample residents. Specifically, the facility failed to provide mental health counseling services for Resident #2 and Resident #4.Findings include:I. Facility policy and procedureThe Behavioral Health Services policy, reviewed on 9/6/24, was received from the nursing home administrator (NHA) on 12/4/24 at .. Based on observations, record review and interviews, the facility failed to provide care and services for an activity of daily living (ADL) for four (#13, #5, #9 and #14) out of five residents reviewed out of 14 sample residents. Specifically, the facility failed to ensure meal assistance was provided for Resident #5, Resident #9, Resident #13 and Resident #14, who required physical assistance and encouragement with food intake. Findings include: I. Resident #13A. Resident statusResident #13, age 77, was admitted on 3/11/22 and re-admitted on 10/20/22. According to the December 2024 computerized physician orders (CPO), diagnoses include Turner Syndrome (absence of one X chromosome in females, .. Based on record review and interviews, the facility failed to ensure the discharge summary was complete for two (#7 and #8) of three residents reviewed for discharge out of 14 sampled residents. Specifically, the facility failed to ensure completed discharge summaries were completed and included a recapitulation of the resident' s stay for Resident #7 and Resident #8. Findings include:I. Resident #7A. Resident statusResident #7, age 80, was admitted on 8/7/24 and discharged home on 8/21/24.. According to the August 2024 computerized physician orders (CPO), diagnoses included bilateral hip osteoarthritis and bilateral total hip replacement.Based on a health status note on 8.. Based on record review and interviews, the facility failed to manage pain in the manner consistent with professional standards of practice for one (#11) of four residents reviewed for pain out of 14 sample residents.Specifically, the facility failed to ensure Resident #11' s pain was managed appropriately and consistently to meet the resident' s stated level of acceptable pain. Findings include: I. Facility policy and procedureThe Pain Assessment and Management policy, reviewed 9/5/24, was received from the nursing home administrator (NHA) on 12/4/24 at 1:01 p.m., read in pertinent part, "Based on the comprehensive assessment of a resident, this facility must ensure that residents receiv..

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/05/2024 and 02/11/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.