Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to follow their policy in providing Activities of Daily
Living (ADLS) when showers/bed bath were not provide as scheduled for 17 of 25 sampled residents
(Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12,13,14,15,16, and 17).This failure had the potential to result in
skin irritation, odor, and decreased quality of life for the residents.Findings:During a concurrent interview
and record review of the Shower Schedule Station 2 with the Certified Nursing Assistant (CNA 2), on July
9, 2025, at 2:36 PM, CNA 2 stated they have residents who complained about not receiving showers on
Saturdays. Review of the Shower Schedule Station 2 document indicated the following schedule for
Wednesday's and Saturday's:a. Hallway 1, AM shift: 201B, 202B, 207B, 208B, 209A, 210Ab. Hallway 2, AM
shift: 215A, 216A, 220B, 222A, 225Cc. Hallway 3, AM shift: 227B, 228B, 233A, 236Ad. Hallway 1, PM shift:
203A, 209B, 211C, 212Ae. Hallway 2, PM shift: 215B, 214A, 218Bf. Hallway 3, PM shift:228A, 230B,
236BDuring a review of the electronic medical record for Activities of Daily Living (ADLs) Bathing with the
DON, on July 9, 2025, at 4:09PM, there was no documentation indicating that showers/bed baths were
provided for the following residents on subacute (higher level of care and patient assistance) unit: a.
Resident 1, No documentation for June 07, 14, 21 and 28, 2025. July 05, 2025b. Resident 2, No
documentation for June 07, 14, 21, and 28, 2025.c. Resident 3, No documentation for June 07, 14, 21, and
28, 2025.d. Resident 4, No documentation for June 07, 21, 25 and 28, 2025.e. Resident 5, No
documentation for June 11, 14, 21, and 25, 2025.f. Resident 6, No documentation for June 14, 21, and 28,
2025.g. Resident 7, No documentation for June 21, and 28, 2025.h. Resident 8, No documentation for June
14, 2025.i. Resident 9, No documentation for June 14 and 28, 2025.j. Resident 10, No documentation for
June 14, 21, and 28, 2025.k. Resident 11, No documentation for June 21 and 28, 2025.l. Resident 12, No
documentation for June 14 and 21, 2025.m. Resident 13, No documentation for June 07 and 21, 2025.n.
Resident 14, No documentation for June 07, 14, 21, and 28, 2025.o. Resident 15, No documentation for
June 14 and 28, 2025.p. Resident 16, No documentation for June 14, 21, and 28, 2025.q. Resident 17, No
documentation for July 05, 2025. During an interview and record review on July 09, 2025, at 11:59 AM, with
the License Vocational Nurse (LVN1), the shower binder was reviewed. LVN 1 stated there were only two
shower refusals documented. LVN 1 further stated the Director of Staff Development (DSD) is responsible
for checking the shower binder.During an interview and record review on July 09, 2025, at 12:41 PM, with
the CNA 1, CNA 1 stated, We give resident showers and back to bed so treatments can get done. It's not
my responsibility to make sure the team is completing the showers or reviewing the shower binder. CNA1
stated, on June 21, 2025, there should have been a total of nine (9) showers in AM and six (6) in PM. CNA
1 further stated the shower sheets should be in the shower binder; however, it was not, I only see 2 shower
sheets.All subacute residents are dependent on staff for showers.During an interview and record review on
July 09, 2025, at 3:04 PM, with the Registered Nurse (RN), the RN stated the CNAs gives baths, besides
the shower team. RN 1 stated the CNA has to complete a shower form and they should
Residents Affected - Some
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
555435
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555435
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Canyons Post-Acute
1350 Reche Canyon Rd
Colton, CA 92324
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
document in electronic record. RN 1 further stated, There is no proof of it because it was not
documented.During an interview and record review of the Shower Binder Station 2, on July 09, 2025, at
3:54 PM, with the DSD, DSD stated the shower binder is reviewed to make sure it is completed and filled by
licensed staff. The DSD stated showers should be documented in shower binder and in electronic records.
The DSD further stated CNAs should be reporting to charge nurse or Registered Nurse if the residents did
not receive a shower, I did not receive report about this.During an interview and record review of the
Shower Binder Station 2, on July 09, 2025, at 4:02 PM, with the Assistant Director of Nursing (ADON),
ADON stated, the charge nurse and RN are supposed to check and follow up after the CNAs; the CNAs
report to them about refusals. The nurse signs when the resident refused. ADON agreed, the staff should
provide showers and document it as scheduled.During an interview and record review of the Shower Binder
Station 2, on July 09, 2025, at 4:09 PM, with the Director of Nursing (DON), DON stated she was not aware
of the shower binder audit. The DON further stated CNAs know when they have a shower team and when
they do not. The DON agreed, the staff should provide showers and document it as scheduled.During a
review of the facility's policy and procedure titled, Activities of Daily Living ADL, supporting revised March
2018, the policy and procedure indicated, Residents will be provided with care, treatment, and services as
appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who
are unable to carry out activities of daily living independently will receive the services necessary to maintain
good nutrition, grooming and personal and oral hygiene.(3) refuses care and treatment to restore or
maintain functional abilities and (a) the resident and or representative has been informed of the risk and
benefits of the proposed care or treatment.(c) the refusal and information are documented in the residents
clinical record.2. Appropriate care and services will be provided for residents who are unable to carry out
ALDs independently, with the consent of the resident and accordance with the plan of care, including
appropriate support and assistance with: a. hygiene (bathing, dressing, grooming and oral care).
Event ID:
Facility ID:
555435
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555435
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Canyons Post-Acute
1350 Reche Canyon Rd
Colton, CA 92324
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure the Certified Nursing
Assistant (CNA) performed hand hygiene after doffing (removing) Personal Protective Equipment (PPE)
upon leaving the isolation (to keep patients with contagious diseases separate from others) room for two of
25 (Resident 18 and 19).This failure had the potential to spread infectious disease (disease caused by
bacteria, viruses, fungi or parasites) to other residents and staff in the facility.Findings:During a concurrent
observation and interview on July 08, 2025, at 1:54 PM, with the Certified Nursing Assistant (CNA 3), CNA
3 was observed to enter the isolation room for Resident 18 wearing gloves and isolation gown. CNA 3
exited the room and doffed (removed) her (PPE). CNA 3 did not perform hand hygiene after doffing her
PPE. CNA 3 stated she did not touch the resident or anything in the room, that is why she did not do hand
hygiene.During a review of Resident 18's clinical record, the isolation list indicated Resident 18 was placed
on contact precautions on July 08, 2025, due to MDRO-Multidrug Resistant Organism (a type of bacteria
that has become resistant to several antibiotics that are normally used to treat infections).During a review of
Resident 19's clinical record, the isolation list indicated Resident 19 was placed on contact precautions on
on May 17, 2023, due to MDRO-Multidrug Resistant Organism.During an interview with the Director of
Nursing (DON), DON agreed that CNA 3 should have performed hand hygiene.During a review of the
Centers for Disease Control (CDC) guidelines titled Clinical Safety: Hand Hygiene for Healthcare Workers,
dated February 27, 2024, the CDC recommendations included Know when to clean your hands:.(bullet 6)
Immediately after glove removal, to reduce the potential spread of deadly germs to patients including those
resistant to antibiotics.During a review of the facility's policy and procedure titled, Handwashing/Hand
Hygiene revised August 2015, the policy and procedure indicated, This facility considers hand hygiene the
primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand
hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.
8.Hand hygiene is the final step after removing and disposing of personal protective equipment.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555435
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the July 9, 2025 survey of The Canyons Post-Acute?
This was a inspection survey of The Canyons Post-Acute on July 9, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at The Canyons Post-Acute on July 9, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.