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Complaint Investigation

Canyon View Care Center

August 13, 2025 · Palisade, CO · 151 E 3rd St
Citations 1
CMS Rating 2/5
Beds 88
Provider ID 065228
Healthcare Facility
Canyon View Care Center
Palisade, CO  ·  View full profile →
Inspection Summary

CANYON VIEW CARE CENTER in PALISADE, CO — inspection on August 13, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

behaviors.B.

Record reviewResident #2's comprehensive care plan, revised 6/2/25, documented she received physical aggression from another resident.

Interventions included assessing and addressing for contributing sensory deficits (initiated 6/2/25), assessing and addressing for contributing sensory deficits (initiated 6/2/25), sitting with the resident and taking her for a walk outside as needed (initiated 6/2/25) and monitoring for any signs of other residents posing danger to the resident (initiated 6/2/25).A progress note, dated 6/13/25, documented a resident (Resident #1) was sitting in the dining room chair as she watched television. Resident #2 stood behind the resident's chair and next to a CNA. Resident #2 placed her hand on the back of the resident's chair.

The resident (Resident #1) reached up and said Do not touch me! Resident #1 grabbed Resident #2 by the arm with her fingernails, which resulted in three red areas and one superficial open area on Resident #2's right forearm.

The CNA stepped between the residents and separated them.

The resident attempted to hit Resident #2 again, but the staff prevented her from making contact. Resident #1 was asked to go to her room until she was calm.VII.

Staff interviewsThe memory care director was interviewed on 8/13/25 at 11:20 a.m.

The memory care director said the staff on the dementia unit prevented resident-to-resident altercations and behaviors with snacks and a lot of redirection.

The memory care director said all staff received dementia training once a year.

She said Resident #1 was sometimes volatile but had recently calmed down.

She said Resident #1 was good at leaving the area if she was anxious, but often tried hitting others who invaded her personal space.

The NHA was interviewed on 8/13/25 at 11:35 a.m.

The NHA said it was important to update care plans with new interventions because whatever was previously in place obviously did not work.

She said it was important to prevent resident-to-resident abuse to prevent fear or injuries.

The NHA said she felt Resident #1 did not instigate the altercations for either incident.

The NHA said the root cause of the incident on 6/13/25 appeared to be the dining room was cluttered and Resident #2 got in Resident #1's personal space.

The NHA said Resident #3 was the one who was agitated and near Resident #1's doorway on 5/28/25.

She said both incidents of abuse were substantiated.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PALISADE, CO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CANYON VIEW CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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