Bear Canyon Rehab: Blood Thinner Missed for Months - NM
The resident, identified as R #42, was prescribed clopidogrel 75 mg daily following a hospital stay in October 2024. The medication helps prevent blood clots in patients with stroke history and vascular conditions. Staff never administered a single dose.
Federal inspectors discovered the medication error during a February inspection that resulted in an immediate jeopardy citation — the most serious level of violation indicating substantial likelihood of death or serious injury.
The Medical Director confirmed during a February 6 interview that hospital discharge records contained the clopidogrel order. He verified staff missed the order entirely and never administered the medication since the resident's admission to the facility.
"He stated R #42 should have received clopidogrel while at the facility," inspectors wrote after interviewing the facility's Nurse Practitioner on February 7.
The Director of Nursing admitted she missed the resident's clopidogrel order when verifying admission medications. Her oversight meant the stroke patient went without antiplatelet therapy designed to prevent potentially fatal blood clots.
Medication administration records from October 2024 through February 6, 2025 showed no doses of clopidogrel given to the resident. The hospital had originally prescribed the medication starting October 11, 2024, along with instructions to continue Lipitor and Plavix — another brand name for clopidogrel.
The resident's medical conditions made the missed medication particularly dangerous. Sequelae of cerebral infarction indicates ongoing complications from stroke. Combined with systolic and diastolic heart failure and peripheral vascular disease, the patient faced elevated risks for blood clots without proper antiplatelet therapy.
Inspectors notified the facility Administrator of the immediate jeopardy finding on February 7 at 10:42 am. The facility submitted a plan of removal that same day, which regulators approved at 3:15 pm.
The correction plan included auditing all stroke patients to ensure antiplatelet medications were properly ordered. Staff also reviewed recent admissions for accurate medication reconciliation and provided education to all licensed nursing staff on medication transcription procedures.
Additional medication safety problems emerged during the inspection. Nurses failed to properly label and dispose of insulin pens, creating risks for diabetic residents.
Three opened insulin glargine pens belonging to resident R #19 were found undated on a medication cart. Manufacturer instructions require discarding opened insulin pens after 28 days, even with medication remaining.
Nurse #12 acknowledged the pens belonged to an active patient receiving the insulin. "He stated he should have dated the insulin glargine pens and discarded them within 28 days of the opening date," inspectors noted. "Nurse #12 stated he just missed it."
The Director of Nursing and facility pharmacist both confirmed staff must date opened insulin pens and dispose of them within 28 days to ensure medication effectiveness.
Inspectors also observed an unlocked medication cart left unattended on the 200 unit at 7:47 am. The registered nurse on duty confirmed medication carts should remain locked and secured when not directly supervised.
Training deficiencies compounded the medication safety issues. Four of five certified nurse aides reviewed failed to complete required annual training hours.
CNA #4 completed only 6.33 hours of the mandatory 12 hours. CNA #5 finished 6.30 hours. CNAs #6 and #7 received just over one hour each — 1.22 and 1.38 hours respectively.
The Director of Nursing acknowledged during a February 6 interview that the four aides had not received additional training during the previous 12 months. She admitted awareness that the CNAs failed to meet annual training requirements.
Federal regulations require certified nurse aides to complete at least 12 hours of in-service education annually to maintain skills necessary for resident care, including dementia care and abuse prevention training.
The facility's corrective measures included implementing daily medication reconciliation audits during morning clinical meetings. The Director of Nursing or designee will audit five random residents three times weekly to verify proper medication reconciliation.
Results will be presented to the Quality Assurance and Performance Improvement committee monthly for the next two months or until ongoing compliance is achieved. The committee operates under Administrator oversight.
All licensed staff received education on medication transcription and reconciliation procedures. Staff members on leave, vacation, or working as-needed schedules will complete the training before returning to duty. New hires will receive the education upon employment.
The Nurse Practice Educator began staff education on February 7, continuing until all licensed nursing personnel completed training prior to their next shift.
Bear Canyon Rehabilitation Center disputed the citations but implemented the required corrections. Federal inspectors verified the plan's implementation during their February 10 visit and reduced the scope and severity level after confirming compliance measures.
The immediate jeopardy finding was lifted, but the medication error that left a stroke patient without blood-thinning therapy for months highlighted systematic failures in medication management and staff oversight that put vulnerable residents at risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bear Canyon Rehabilitation Center from 2025-02-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
Bear Canyon Rehabilitation Center in Albuquerque, NM was cited for violations during a health inspection on February 10, 2025.
The resident, identified as R #42, was prescribed clopidogrel 75 mg daily following a hospital stay in October 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.