North Canyon Care Center: Immediate Jeopardy Violations - UT

The resident, identified as Resident 12, was observed smoking independently despite having "abrupt, jerking movements" with both hands and visible burn damage to his plaid pajama bottoms, according to the inspection report. At 12:30 PM on January 28, inspectors watched him drop his cigarette on the ground, lean over to pick it up, and continue smoking it.

The facility's smoking policy required all residents to be supervised while smoking, yet staff had assessed multiple residents as safe to smoke independently without proper safety evaluations or protective equipment.

Resident 12 was admitted with diagnoses including schizophrenia, chronic obstructive pulmonary disease, type 2 diabetes, and emphysema. His care plan from January 2024 stated he could smoke "unsupervised" and that his cigarettes should be stored in a locked box by the nurses station, with staff instructed to "observe clothing and skin for signs of cigarette burns."

Licensed Practical Nurse 1 completed a smoking assessment on January 21 but told inspectors there was "no score on the assessment." He stated he had not noticed anything about Resident 12 that would be unsafe for independent smoking, despite the visible tremors and burn damage.

"LPN 1 stated he had not noticed anything about resident 12 that he would consider unsafe to smoke independently," the report states.

The smoking violations extended beyond Resident 12. Inspectors found that Residents 5 and 23 were observed sharing a single lit cigarette, passing it back and forth between them in the smoking area. Resident 5's smoking evaluation had documented that she was "unable to retrieve a cigarette if it were dropped" and "used medications that could cause drowsiness," yet no supervision requirements were implemented.

Resident 34 was listed as needing assistance getting outside but had no smoking assessment in his medical record despite having a care plan stating he needed supervised smoking. Staff told inspectors he frequently removed his oxygen tubing and had to be encouraged to put it back on.

The facility's written smoking policy, revised in March 2019, explicitly required that "residents who smoke will be supervised by staff members while smoking" and that "smoking assessments will be completed on admission, quarterly, with significant change of condition and as needed for residents who wish to smoke."

Director of Nursing acknowledged the policy violations after witnessing Resident 12's condition firsthand. "The DON stated he had observed resident 12 with a burn hole in his pants and involuntary movement," inspectors noted. "The DON stated resident 12 was being placed on supervised smoking going forward."

The Administrator told inspectors he was unaware of the smoking safety issues. "The ADM stated he did not know resident 12 very well and had not observed any type of uncontrolled movement when talking with resident 12," the report states.

The immediate jeopardy designation was removed on January 30 after the facility implemented corrective measures including reassessing all smoking residents for safety, removing smoking materials from rooms, and requiring supervised smoking for at-risk residents.

Beyond smoking safety, inspectors found the facility failed residents in multiple critical areas. Resident 18, who had severe cognitive impairment and was a documented fall risk, was found sleeping in bed with no call light within reach. The resident had fallen four times between September 2024 and January 2025, including incidents where she was "found on floor next to her bed" and sustained a skin tear to her right forearm.

Despite the repeated falls, no updated interventions were added to her care plan until January 3, when staff noted only "education to be provided about alarm use."

The facility also failed to provide appropriate mental health care for Resident 28, who had post-traumatic stress disorder, anxiety, and major depressive disorder. Administration repeatedly threatened to move the resident from her private room or assign her a roommate, causing what a physician documented as exacerbated symptoms.

"The resident states that this has made [the resident] more depressed and made it more difficult for [the resident] to sleep," a January 30 physician note stated. "[The resident] complains of increased anxiety and constant worry."

The resident's room door was covered with six signs requesting quiet, specific care instructions, and warnings about scent sensitivities. Despite clear documentation of the resident's need for a private room and female-only caregivers due to PTSD, male nursing assistants were assigned to her care, causing additional distress.

Medication errors plagued the facility's antibiotic management. Resident 3, who was receiving vancomycin for a serious infection, experienced multiple dosing problems and missed laboratory tests that left physicians unable to determine proper antibiotic levels.

"Later in the evening, there was an issue with her vancomycin dosing, unable to ascertain her vancomycin level at the moment but needing a vancomycin dose after dialysis today," a January 6 physician note stated. The physician had to estimate the dose "with emphasis to obtain vancomycin level as soon as possible so as to allow proper dosing."

Nursing staff administered vancomycin without proper physician orders and failed to obtain required blood tests, forcing the physician to "guess what the dosing was because there was not a trough drawn," according to one nurse's testimony.

The facility's food service drew consistent complaints from residents about cold meals and poor quality. Multiple residents told inspectors their food was frequently cold, with one noting that "plate warmers were not being used."

Resident council meeting minutes from August 2024 through January 2025 repeatedly documented "cold food" as an ongoing problem, with staff attributing the issue to weekend cooks not using plate warmers "because of laziness," according to the Dietary Manager.

Infection control failures included nurses handling medications with bare hands and failure to implement enhanced barrier precautions for residents with wounds and medical devices. One nurse was observed "placing resident 3's medications directly into bare hands before transferring them into a medication cup" and handling multiple residents' medications without gloves.

The facility also failed to maintain complete medical records, with shower documentation stored separately from residents' charts and wound care orders that didn't match specialists' recommendations.

North Canyon Care Center, operated by Monument Healthcare, serves residents requiring skilled nursing and rehabilitation services. The facility's immediate jeopardy finding was the most serious level of noncompliance, indicating conditions that posed immediate risk to resident health and safety.

The inspection covered 33 residents and resulted in violations across multiple areas of care, from basic safety protocols to complex medical management. While the immediate jeopardy was lifted after corrective actions, the breadth of deficiencies suggests systemic problems in the facility's operations and oversight.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for North Canyon Care Center from 2025-02-06 including all violations, facility responses, and corrective action plans.

Additional Resources

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