Rock Canyon Respiratory and Rehabilitation Center

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

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.

Gas, Vacuum, and Electrical Systems Deficiencies

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

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.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

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.

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Quality of Life and Care Deficiencies

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

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Rights Deficiencies

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.

Nutrition and Dietary Deficiencies

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

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

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

Construct fire resistant interior walls.

A complaint survey, prompted by #CO2638255, Incident #2595214, Incident #2595239 and Incident #2612764 was conducted on 10/13/25 to 12/11/25. One deficiency was cited.The actual exit date was 10/14/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider, on 12/11/25. Based on observations, record review and interviews, the facility failed to ensure one (#7) of eight residents reviewed for abuse out of 13 sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #7 from physical abuse by Resident #6. Findings include:I. Facility investigationThe facility investigation, dated 7/11/25, was provided by the DON on 10/14/25 at 12:44 p.m. The investigation revealed the following:On 7/11/25 Resident #6 was attempting to take food from a female resident (Resident #7). The female resident told Resident #6 to stop and Resident #6 hit the female resident. This incident occurred on the secured unit. The residents were separated and Resident #6 was given a new plate of food. Staff sat with Resident #6 until he was done with his meal and calmed down. Resident #7 was assessed and did not have any noted injuries. Neither resident was able to recall the incident.Interviews with facility staff members revealed Resident #6 approached Resident #7 and grabbed some of her food. Resident #7 yelled at Resident #6, and he hit her.A root cause analysis of the incident revealed Resident #6 attempted to take Resident #7’s food, Resident #7 told him not to, and Resident #6 hit her as a result. Resident #6 did not have his meal yet and was hungry. The root causes of the incident were determined to be Resident #6’s hunger, and Resident #6’s dementia not allowing for the cognition that Resident #7’s food was not his own.The investigation documented Resident #7 did not have a history of behaviors and did not have a behavior care plan. The investigation indicated Resident #7 had not been involved in any other occurrences.The investigation documented Resident #6 had a history of behaviors, including becoming aggressive, pushing furniture around the dining room and being resistant to care. The resident’s care plan included interventions which documented the resident could become physically aggressive and was not easily redirectable.The investigation concluded the incident of physical abuse was found to h..

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1.No fuel test report available for review .. Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: K918 - No fuel test report available for review K918 - Generator battery testing states specific gravity testing being conducted | However facility has sealed batteries | Conductivity testing was only recorded once.. *** CITATION TEXT NOT FOUND *** Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally The initial comments (ID Prefix Tag #K000) are informational only, and are a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a) Life safety features that met the requirements at the time of licensure or certification shall be maintained and not be diminished. This facility, licensed for 141 beds and at the time of this survey, is a fully-sheathed, one-story, Type V (000) structure without a basement. This facility is fully protected by a National Fire Protection Association (NFPA) Type 13 automati..

A recertification survey with complaint #CO40105, #CO40158, Incident #40147, Incident #40148, Incident #40149, Incident #40150 and Incident #40175 was completed on 6/2/25 to 6/5/25. Six deficiencies were cited. An Emergency Preparedness survey was conducted from 6/2/25 to 6/5/25. No deficiencies were cited. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of four units.Specifically, the facility failed to:-Ensure housekeeping staff followed the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas;-Ensure housekeeping .. Based on observations, record review and interviews, the facility failed to ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion (ROM) and/or prevent further decrease in ROM for one (#33) of three residents reviewed for restorative services out of 43 sample residents.Specifically, the facility failed to ensure Resident #33' s bilateral hand contracture soft splints were applied .. Based on observations, record review and interviews, the facility failed to ensure one (#53) of five residents out of 43 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to ensure the physician' s orders for Resident #53 contained the appropriate dose of the medication that was to be administered to the resident. Findings include: I. Professional referenceAccording to the National Institutes of Health.. Based on observations, record review and interviews, the facility failed to ensure residents were free from chemical restraints for one (#122) of five residents out of 43 sample residents. Specifically, the facility failed to ensure Resident #122, who was on antipsychotic medication, received appropriate monitoring to ensure signs and symptoms of tardive dyskinesia (involuntary movements) did not worsen. Findings include: I. Professional reference According to the Nati.. Based on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#15) of six residents reviewed for medication errors of 43 sample residents.Specifically, the facility failed to ensure that Resident #15 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration..Findings include:I. Professional referenceAccording to .. Based on observations, record review and interviews, the facility failed to provide reasonable accommodation necessary to accommodate mobility and accessibility in the residents' environment for two (#119 and #120) of seven residents reviewed out of 43 sample residents. Specifically, the facility failed to ensure Resident #119 and Resident #120' s call lights were within reach when the residents were in bed.Findings include:I. Facility policy and procedureT..