Bear Canyon Rehabilitation Center
Bear Canyon Rehabilitation Center in Albuquerque, NM — inspection on February 10, 2025.
Found 12 citations. 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.
Inspection Findings
medications for 1 (R #70) of 3 (R #31, R #58 and R #70) residents reviewed for unnecessary
medication, they are not able to make informed decisions.
The findings are: A.
Record review of R #70's physician's orders revealed the following: - An order for buspirone HCI oral tablet (antianxiety medication), 5 milligrams (mg.) Give one tablet by mouth two times a day for anxiety/depression.
Start date: 07/13/24. - An order for citalopram hydrobromide oral tablet (antidepressant medication) 10 mg.
Give two tablets by mouth one time a day for depression, crying, wandering into other resident rooms, inability to redirect, hitting staff, and screaming.
Start date: 01/11/24.
B.
Record review of R #70's medical record revealed the record did not contain a consent form from the resident/responsible party for the buspirone 5 mg tablets and for the citalopram 10 mg tablets.
C. On 02/06/25 at 12:52 pm during an interview, the Director of Nursing (DON) verified R #70's medical record did not contain consent forms for the buspirone 5 mg and the citalopram 10 mg.
She stated there should be a signed consent form for R #70's antianxiety and antidepressant medications.
325125 02/10/2025
Bear Canyon Rehabilitation Center 5123 Juan Tabo Boulevard NE Albuquerque, NM 87111
to participate in experimental research, and to formulate an advance directive.
record review and interview, the facility failed to ensure the resident's current advance directive (a
documented for 1 (R #16) of 1 (R #16) resident reviewed for advance directives.
This deficient practice is likely to cause confusion and delay potentially lifesaving procedures.
The findings are: A.
Record review of R #16's face sheet revealed R #16 was admitted into the facility on [DATE].
B.
Record review of R #16's facesheet, dated [DATE], revealed R #16's advanced directive was Full Code (desired life saving procedures, such ascardiopulmonary resuscitation (CPR)).
C.
Record review of R #16's physician orders, dated [DATE], revealed R #16 chose Do Not Resuscitate [DNR; does not want to have CPR attempted on them if their heart or breathing stops] for her advanced directive code status.
D. On [DATE] at 1:05 PM during an interview with the Director of Nursing (DON), she stated R #16's code status should be DNR and not Full Code.
325125 02/10/2025
Bear Canyon Rehabilitation Center 5123 Juan Tabo Boulevard NE Albuquerque, NM 87111
A.
Record review of R #42's face sheet, dated 10/23/24, revealed an initial admission with the following diagnoses: - Cerebral palsy (group of conditions that affect movement, and posture caused by brain damage before birth), - Muscle weakness, - Lack of coordination, - Difficulty in walking, - Sequelae of cerebral infarction (long term effects and complications that can occur after a stroke), - Iron insufficiency anemia (when there is not enough iron in the blood), - Reduced mobility, - Peripheral vascular disease (PVD; disorder that causes abnormal narrowing of arteries).
B.
Record review of R #42's hospital discharge orders, dated 10/23/24, revealed an order for clopidogrel (blood thinning medication) 75 milligrams (mg) daily.
Route: Oral (by mouth).
Date first scheduled: 10/11/24.
C.
Record review of R #42's admission MDS, dated [DATE], revealed the following: - Active diagnoses: Cerebrovascular accident (CVA; stroke), transient ischemic attack (TIA; when blood flow to part of the brain stops for a brief period of time), or stroke. - Medications: Antiplatelet and/or anticoagulant were not selected.
D. On 02/07/25 at 9:18 am during an interview, the DON stated she expected the information in R #42's admission MDS and hospital discharge documentation to match, but they did not.
325125 02/10/2025
Bear Canyon Rehabilitation Center 5123 Juan Tabo Boulevard NE Albuquerque, NM 87111
practical level of well-being.
The findings are: A.
Record review of R #42's face sheet, dated 10/23/24, revealed an initial admission with the following diagnoses: - Cerebral palsy (group of conditions that affect movement, and posture caused by brain damage before birth), - Muscle weakness, - Lack of coordination, - Difficulty in walking, - Sequelae of cerebral infarction (long term effects and complications that can occur after a stroke), - Abnormalities of gait and mobility, - Reduced mobility - Iron deficiency anemia (low iron levels in the blood), - Peripheral vascular disease (PVD; disorder that causes abnormal narrowing of arteries).
B.
Record review of R #42's hospital discharge orders, dated 10/23/24, revealed an order for clopidogrel (blood thinning medication) 75 milligrams (mg) daily.
Route: Oral (by mouth).
Date first scheduled: 10/11/24.
C.
Record review of R #42's Baseline Care Plan, dated 10/24/24, revealed the baseline care plan did not include the use of antiplatelet medication (medication that is used to help prevent blood clots.) D. On 02/07/25 at 9:18 am during an interview, the Director of Nursing (DON) stated that when she verified R #42's admission orders, she missed the order for clopidogrel (antiplatelet medication) and that may be why there was no mention of the antiplatelet medication on his baseline care plan.
325125 02/10/2025
Bear Canyon Rehabilitation Center 5123 Juan Tabo Boulevard NE Albuquerque, NM 87111
325125 02/10/2025
Bear Canyon Rehabilitation Center 5123 Juan Tabo Boulevard NE Albuquerque, NM 87111
#8) CNAs sampled for annual training.
This deficient practice could likely result in staff being
A.
Record review of the facility's employee competencies revealed CNA #6 and CNA #7 did not have a competency assessment (an evaluation of skills, knowledge, and core abilities required for fulfilling job duties) completed during the last twelve months.
B. On 02/06/25 at 10:56 am, during an interview with the Director of Nursing (DON), she stated she did not have any documentation to show competency assessments were completed for CNA #6 and CNA #7 during the last twelve months.
C. On 02/06/25 at 11:32 am, during an interview with the Educator, she stated staff competency assessments should be completed yearly in order to identify what trainings staff need.
She could not state if all of the staff had a competency assessment completed in the last year.
325125 02/10/2025
Bear Canyon Rehabilitation Center 5123 Juan Tabo Boulevard NE Albuquerque, NM 87111
following irregularity reporting guidelines in developed policies and procedures.
was free from unnecessary medications for 1 (R #104) of 1 (R #104) residents, when the attending
- Did not provide clinical basis when he disagreed with the facility's pharmacist consultant's recommendation on R #104's Medication Regimen Review (MMR), - Did not document in R #104's medical record the action he took to address the recommended medication dose reduction.
This deficient practice is likely to cause R #104's medication regimen to not be properly evaluated resulting in a possible over medication.
The findings are: A.
Record review of R #104's face sheet, dated 09/17/24, revealed R #104 was under psychiatric care (branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders.) B.
Record review of R #104's physician orders revealed the following: - On 09/13/24, R #104's psychiatrist entered an order for quetiapine (an antipsychotic medication) 12.5 milligrams (mg) twice daily for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). - On 09/17/24, R #104's psychiatrist entered an order for trazodone (antidepressant and sedative) 50 mg once nightly for insomnia (a sleep disorder that makes it hard to fall asleep or stay asleep).
C.
Record review of R #104's MMR, dated 11/11/24, revealed the following: - The facility's consultant pharmacist recommended to evaluate the current dose and to consider a dose reduction for two the antipsychotic medications, quetiapine and trazodone. - The facility's attending physician responded to continue the same orders, and R #104's psychiatrist was following the resident's care.
D. On 02/07/25 at 3:20 pm, during an interview with the facility's Medical Director, he stated the attending physician who responded to R #104's MMR, dated 11/11/24, did not work at the facility any longer.
The Medical Director stated he expected the previous attending physician to consult with R #104's psychiatric provider, in order to evaluate the recommended medications dose reduction, to examine R #104's response to the antipsychotic medications, and to make a decision on the recommended medications dose reduction.
E. On 02/12/25 at 3:45 pm, during an interview, the facility's consultant pharmacist stated she expected the previous attending physician to consult with R #104's psychiatrist to decide on R #104's medication dose reduction.
325125 02/10/2025
Bear Canyon Rehabilitation Center 5123 Juan Tabo Boulevard NE Albuquerque, NM 87111
Based on record review and interview, the facility failed to ensure the resident medication regimen
physician ordered an as needed (PRN) antipsychotic (a class of drugs that treat psychotic symptoms and disorders) medication without a 14 day stop date.
This deficient practice is likely to cause R #104's medication regimen to not be properly evaluated and result in a possible over medication.
The findings are: A.
Record review of R #104's face sheet, dated 09/26/24, revealed R #104 was under hospice care.
B.
Record review of R #104's Hospice Physician order, dated 01/14/25, revealed an order to give haloperidol (antipsychotic medication) 2 milligrams (mg) every six hours PRN for agitation (a feeling of irritability, mental distress or severe restlessness).
The hospice physician entered the stop date as indefinite.
C.
Record Review of R #104's Medication Regimen Review (MMR), dated 01/16/25, revealed the following: - The facility's Pharmacist Consultant recommended an evaluation of R #104's antipsychotic medication order for haloperidol, since the order did not have a 14 day stop date. - The facility's Attending Physician responded that R #104's hospice physician entered the order.
D. On 02/07/25 at 3:20 pm, during an interview with the facility's Medical Director, he stated the Hospice Physician entered R #104's haloperidol order.
The Medical Director stated the Hospice Physician should evaluate R #104's response to the medication and decide to continue or discontinue the order.
E. On 02/12/25 at 3:45 pm, during an interview with the facility's Pharmacist Consultant, she stated R #104 had an order for haloperidol 2 mg every six hours PRN for agitation.
She stated an antipsychotic medication must have a 14 day stop date, but the Hospice Physician entered the stop date as indefinite.
The Pharmacist Consultant stated the Attending Physician should evaluate R #104's response to the medication in order to decide to continue or discontinue the medication.
The Pharmacist Consultant stated the Attending Physician should consult with R #104's Hospice Physician to come up with a decision on R #104's haloperidol order.
325125 02/10/2025
Bear Canyon Rehabilitation Center 5123 Juan Tabo Boulevard NE Albuquerque, NM 87111
- Audit of recent admissions to ensure accurate medication reconciliation, review, and continuation of medications and treatments. - All licensed staff educated regarding medication transcription, medication reconciliation upon admission, and documentation in the resident's chart. - During morning clinical meetings, medication reconciliation audits occur for new admissions and medication order changes. - Nurse Practice Educator or Designee will begin education on 02/07/25 and continue until all licensed nursing staff have been educated prior to their next shift.
Any licensed staff member on leave of absence (FMLA), vacation, or PRN (as needed) staff will be re-educated prior to returning to duty.
New hires will be educated on this process upon hire. - The Director of Nursing (DON) or designee will audit five random residents three times a week to ensure all medications reconciliation have occurred. - The DON or designee will bring results of audits to Quality Assurance and Performance Improvement (QAPI) committee for further recommendations based on tracking and trending. It will be presented monthly for the next two months or until ongoing compliance is achieved.
The QAPI committee is overseen by the Administrator.
325125 02/10/2025
Bear Canyon Rehabilitation Center 5123 Juan Tabo Boulevard NE Albuquerque, NM 87111
Based on observations, interviews, and record review, the facility failed to ensure nurses and
body turn food into energy and manage blood sugar levels) pens and discarded glargine pens within 28 days of opening for 1 (R #19) of 1 (R #19) resident and to ensure medication carts were locked when unattended.
These deficient practices are likely to result in R #19 receiving medications that are less effective or expired and is likely to negatively impact the health of residents on the 200 unit if they were to ingest (swallow) medications not intended for them.
The findings for medication storage are: A.
Record review of R #19's physician orders, dated 02/04/25, revealed R #19 received insulin glargine.
B.
Record review of the manufacturer's instructions for insulin glargine pens, dated 08/2022, revealed staff must throw away all opened pens after 28 days of first use, even if there was insulin left in the pen.
C. On 02/04/25 at 1:47 pm, during an observation of the 600-hall medication cart, three insulin glargine pens were opened and not dated.
The pens belonged to R #19.
D. On 02/04/25 at 1:50 pm, during an interview, Nurse #12 stated the insulin glargine pens belonged to R #19, and the resident actively received it. He stated he should have dated the insulin glargine pens and discarded them within 28 days of the opening date.
Nurse #12 stated he just missed it. He also stated the assigned nurse on each hall should check the expiration date before administering the insulin to the resident.
E. On 02/05/25 at 10:55 am, during an interview with the Director of Nursing, she stated staff must date the opened glargine insulin pens and discard them within 28 days from the opening date.
F. On 02/06/25 at 9:00 am, during an interview, the facility's pharmacist consultant stated she expected nurses and CMAs to date the opened glargine insulin pens and discard them within 28 days from the opening date.
Medication carts: G. On 02/07/25 at 7:47 am, during an observation of the 200-unit medication cart, the medication cart was unattended and unlocked.
H. On 02/07/25 at 7:47 am, during an interview, Registered Nurse (RN) #1 confirmed the medication carts should be locked and secured at all times when left unattended.
dementia care and abuse prevention.
received the required in-service training of at least 12 hours per year for 4 (CNAs #4, #5, #6, and #7)
deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents.
The findings are: A.
Record review of the facility's employee training transcripts, dated 01/01/24 through 12/31/24, revealed the following: - CNA #4 completed 6.33 hours of training. - CNA #5 completed 6.30 hours of training. - CNA #6 completed 1.22 hours of training. - CNA #7 completed 1.38 hours of training.
B. On 02/06/25 at 10:56 am, during an interview with the Director of Nursing (DON), the DON stated CNA #4, CNA #5, CNA #6, and CNA #7 did not have any other trainings during the last 12 months.
She stated she was aware the CNAs did not meet the annual 12 hour training requirement.
325125 02/10/2025
Bear Canyon Rehabilitation Center 5123 Juan Tabo Boulevard NE Albuquerque, NM 87111
Based on record reviews and interviews, an Immediate Jeopardy (IJ) was identified.
The facility Administrator was notified on 02/07/25 at 10:42 am.
325125
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 325125 B.
Wing 02/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bear Canyon Rehabilitation Center 5123 Juan Tabo Boulevard NE Albuquerque, NM 87111
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.