The patient told inspectors two days later: "There was no RT at all. The nurses do not know how to operate the machine; I just stayed off the machine."
Two respiratory therapists had been scheduled to work that night at The Canyons Post-Acute. Both called off.
The facility's timesheet shows respiratory therapist RT 2 clocked out at 10:10 PM on October 12. The next therapist, RT 1, didn't clock in until 4:55 AM on October 13 — a gap of nearly seven hours with no respiratory therapist on duty.
RT 1 discovered the problem when arriving early for the morning shift. "I came early Monday at 5:00 AM, I clocked in before 5:00 AM, there was no RT on duty," the therapist told inspectors. "The scheduled RT called off, and another RT, who lacks work permit, did not report to work."
The facility had tried to address the staffing crisis by extending a day-shift respiratory therapist's hours until 10:00 PM. But that still left the overnight hours uncovered.
RT 2, who worked the extended shift that ended at 10:10 PM, confirmed the situation to inspectors: "They could not find anybody and there was no RT on the floor. I left at 10:00 PM, there was no RT when I left. There was two scheduled, they called off."
The registered nurse working the floor that night acknowledged the problem. "There was no RT, the young lady is not a registered therapist, there was no cover, the scheduled RT called off," the nurse told inspectors.
Federal inspectors found the facility violated requirements to provide safe and appropriate respiratory care. The inspection report noted this failure "had the potential to place clinically compromised residents' health and safety at risk by not having a respiratory therapist available to provide appropriate care when necessary."
Respiratory therapists are specially trained to operate complex breathing equipment and provide care that nurses cannot legally or safely perform. Patients dependent on ventilators, oxygen therapy, or other respiratory support require their specialized skills.
The facility's own staffing policy, dated October 2017, states: "Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment."
When the Director of Nursing was asked during the November inspection if the facility followed this policy, she stated simply: "No."
The patient who stayed off their breathing machine had been suctioned before the respiratory therapist left at 10:00 PM, but then went without the specialized care for the remainder of the night. The inspection report does not detail what medical consequences, if any, resulted from patients being without respiratory therapy services.
Federal inspectors classified this as a violation causing "minimal harm or potential for actual harm" affecting "few" residents. However, respiratory patients are among the most medically vulnerable in nursing homes, often requiring round-the-clock monitoring and intervention.
The October incident highlights chronic staffing challenges facing nursing homes nationwide, particularly for specialized positions like respiratory therapy. Unlike registered nurses, respiratory therapists require specific certification and training that makes them harder to replace on short notice.
The facility had no backup plan beyond extending one therapist's shift partway into the night. When both scheduled overnight therapists called off, administrators apparently made no further efforts to secure coverage for the remaining seven hours.
For the patient who chose to stay off their breathing machine rather than risk improper operation by unqualified staff, those hours represented a direct consequence of the facility's staffing failure. The patient's decision to forgo the medical equipment rather than trust nurses to operate it underscores the specialized nature of respiratory care and the risks created when such expertise is unavailable.
The inspection occurred about a month after the incident, suggesting residents or families may have filed complaints that triggered the federal review. The facility received the citation in November 2025, though the inspection report does not indicate what corrective actions were required or implemented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Canyons Post-acute from 2025-11-18 including all violations, facility responses, and corrective action plans.