Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bear Canyon Rehabilitation Center during CMS and state inspections, most recent first.
Dignity and Respect Deficiencies: A CNA was observed feeding a resident while using a personal cell phone, despite the resident needing assistance with eating and the facility policy prohibiting phone use that distracts from resident care. Another resident with dementia had urine-stained bed linens observed on multiple occasions, and staff interviews confirmed soiled linens should be changed promptly.
Surveyors found that call lights were not accessible for three residents with significant mobility and cognitive impairments, with devices placed on the floor, under the bed, or at the foot of the bed. Staff interviews confirmed that call lights should be within reach, but observations showed this was not consistently done, increasing the risk of accidents and delayed response to resident needs.
A medication cart was left unlocked and unattended in a hallway, with the nursing computer open to the MAR and no staff present. An RN acknowledged leaving the cart unsecured while stepping into a resident's room, and the DON confirmed that all medication carts are expected to remain locked at all times. This failure to secure medications was not in accordance with facility policy.
A resident with COPD and respiratory failure received supplemental oxygen at a flow rate higher than the physician-ordered range on several occasions. Staff did not update the physician's order or document provider notification when the resident's oxygen needs exceeded the prescribed parameters, as confirmed by interviews with the DON, Administrator, and Medical Director.
A resident with multiple complex medical conditions who was dependent on staff for ADL care did not receive scheduled showering assistance as required by their care plan. Only one shower was documented during the resident's stay, with no evidence of refusals, despite the established schedule and the resident's need for assistance. The DON confirmed the lack of documentation and stated that all showers or refusals should have been recorded.
Staff did not ensure proper infection prevention practices related to two cats in the Memory Care Unit, resulting in dried cat feces being found on a resident's floor and bedding, and uncertainty among staff about cleaning responsibilities. Additionally, the cats did not have nail covers, and there was a reported incident of a resident being scratched, with unclear protocols for nail trimming and litter box maintenance.
A lawn sprinkler head protruding about 6 inches above ground in the memory care unit courtyard created a trip hazard, as observed when a person tripped over it while walking toward a gate. The Administrator was aware of the sprinkler's position but reported no known incidents, and the Maintenance Director stated the sprinkler should have been recessed.
Surveyors found that oxygen cannulas were left on the floor and unbagged on wheelchair handles in the memory care unit. A resident had an unbagged cannula wrapped around a wheelchair, and two cannulas connected to concentrators were found on the floor, one of which was walked over by a cat. Staff interviews revealed inconsistent knowledge and practices regarding proper cannula storage and replacement.
A resident with a history of cerebrovascular accident and other conditions was not monitored for stroke symptoms or administered clopidogrel, a blood thinner, as ordered. The facility's staff failed to transcribe and administer the medication from the hospital discharge records, leading to an Immediate Jeopardy situation. Interviews revealed that the oversight occurred during the post-admission review, and the resident was aware of the need for the medication.
A resident with a history of stroke and heart failure did not receive clopidogrel as ordered upon admission to the facility. The medication was omitted from October 2025 through February 6, 2025, due to a missed order during the verification of admission orders. This oversight was confirmed by the Medical Director, DON, and NP.
The facility failed to ensure CNAs received the required 12 hours of in-service training annually. Four CNAs completed significantly fewer hours than required, with one completing only 1.22 hours. The DON acknowledged awareness of this deficiency.
A facility failed to ensure a resident or their guardian was informed about the medications prescribed, including buspirone and citalopram, as the medical record lacked consent forms. The DON confirmed the absence of these forms, which are necessary for informed decision-making.
A facility failed to properly document a resident's advance directive, resulting in a discrepancy between the face sheet and physician orders. The face sheet listed the resident as Full Code, while the physician orders indicated a DNR status. The DON confirmed the resident's code status should be DNR, highlighting a documentation error that could lead to confusion and delay in emergency care.
A facility failed to ensure the accuracy of the MDS for a resident with multiple diagnoses, including cerebral palsy and peripheral vascular disease. The resident was prescribed clopidogrel, but the MDS did not reflect the use of antiplatelet or anticoagulant medications. The DON acknowledged the discrepancy between the MDS and hospital discharge documentation.
A facility failed to include a blood-thinning medication in a resident's Baseline Care Plan upon admission. The resident had multiple diagnoses, including cerebral palsy and peripheral vascular disease, and was prescribed clopidogrel. The DON admitted to missing the medication order, leading to its omission from the care plan, which could impact the resident's health.
The facility failed to complete annual competency assessments for two CNAs, as revealed by a record review. The DON confirmed the absence of documentation for these assessments, and the Educator acknowledged the importance of yearly evaluations to identify training needs but could not confirm their completion.
A resident's medication regimen was not properly evaluated due to the attending physician's failure to provide a clinical basis for disagreeing with a pharmacist's recommendation for dose reduction and lack of documentation in the medical record. The resident was under psychiatric care and prescribed quetiapine and trazodone. The attending physician did not consult with the resident's psychiatrist, leading to potential over-medication.
A facility failed to ensure a resident's medication regimen was free from unnecessary medications when a hospice physician ordered a PRN antipsychotic medication without a 14-day stop date. The resident, under hospice care, had an order for haloperidol 2 mg every six hours as needed for agitation, with the stop date entered as indefinite. The Pharmacist Consultant recommended an evaluation of the order, and the Medical Director and Pharmacist Consultant emphasized the need for the hospice physician to evaluate the resident's response to the medication.
The facility failed to date and discard insulin glargine pens within 28 days for a resident, as required by the manufacturer's instructions. Additionally, a medication cart was found unlocked and unattended, which was confirmed by an RN as against protocol. These deficiencies could lead to residents receiving ineffective medications and unauthorized access to medications.
A resident, dependent on staff for showers, did not receive necessary ADL assistance during a six-week stay at the facility. Despite family requests, the resident was not showered, wore the same soiled gown for a week, and lacked oral care. The facility's shower logs lacked documentation, and the DON confirmed no records of shower offers or refusals.
A resident in hospice care experienced a decline in condition that went unrecognized by the facility for seven days. The facility failed to notify the physician and POA, assess the cause of the decline, or provide necessary treatment. Despite the POA's request to send the resident to the hospital, the facility delayed the transfer by 15 hours. Upon hospital arrival, the resident was found to be in critical condition, requiring immediate medical intervention.
A facility failed to notify a resident's POA of the resident's decline, medication refusal, and lack of eating or drinking. Despite significant changes in the resident's condition, there was no documentation of communication with the POA. The POA only learned of the situation through a friend and requested hospital transfer.
Dignity and Respect Deficiencies
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect for 2 residents reviewed for resident dignity. For one resident who required staff assistance while eating, a CNA was observed attempting to feed the resident while also using her personal cell phone. The facility's Personal Cell Phone Policy stated cell phones and other portable communication devices should never be used in any way that would distract from resident care or customer service, and the CNA acknowledged that personal cell phone use while feeding a resident was not allowed and that she should not have been using her phone while assisting with feeding. The DON stated it was her expectation that staff do not use personal cell phones while feeding residents who require assistance. For another resident with dementia and benign prostatic hyperplasia who required assistance with ADL care related to cognitive decline, the resident's bed linens were observed on multiple occasions to have urine stains present. The linens were observed stained during several separate observations over a span of days. An LPN stated that if residents soiled their linens, the bed linens should be changed immediately or in a timely manner and not several hours later, and the DON stated soiled bed linens should be changed daily and promptly when noted to be soiled. The DON also stated the resident's bed linens should have been changed as soon as possible once they contained urine on them.
Call Lights Not Accessible for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that call lights were accessible and within reach for residents at risk for falls and injury, as required by their Call Light Policy. During observations, call lights for three residents with significant mobility and cognitive impairments were found out of reach: one call light was on the floor next to the bed, another was under the bed frame near equipment, and a third was placed on top of an air pump at the foot of the bed. These residents had diagnoses including repeated falls, muscle weakness, hemiplegia, hemiparesis, major depressive disorder, insomnia, lack of coordination, seizures, muscle spasms, and contractures, all of which increased their vulnerability to accidents if unable to summon assistance. Interviews with CNAs confirmed that call lights should not be placed on the floor or at the foot of the bed, and that they should be secured within the resident's reach to allow them to call for help when needed. The Director of Nursing also stated that all call lights should be clipped to the resident's beds to ensure accessibility. The failure to follow these procedures resulted in call lights being inaccessible for all three residents reviewed, creating the potential for accidents and delayed response to resident needs.
Unattended and Unlocked Medication Cart Found in Hallway
Penalty
Summary
A medication cart was observed on the 500 Hall with its drawers unlocked and the nursing computer open to the medication administration record (MAR), while no staff were present in the immediate area. This left the cart and its contents, including resident medications, unattended and accessible to residents passing through the hallway. The facility's Medication Storage and Security Policy requires all medications to be secured at all times, with medication carts locked when not in the direct possession of licensed staff, and controlled substances stored in a separately locked compartment. During interviews, a registered nurse (RN) admitted to leaving the cart unlocked while stepping into a resident's room, acknowledging that the cart contained narcotics in a locked box and other resident medications in the remaining drawers. The Director of Nursing (DON) confirmed the expectation that all medication carts remain locked at all times to prevent unauthorized access. The incident demonstrated a failure to follow facility policy and ensure the security of medications, including controlled substances.
Failure to Update Oxygen Orders for Resident with Increased Oxygen Needs
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypercapnia, and hypoxia was admitted with a physician's order to titrate supplemental oxygen between 1 to 5 liters per minute (L/min) to maintain oxygen saturation between 88% and 92%. Record reviews showed that on multiple occasions, the resident received oxygen at a flow rate of 6 L/min, which exceeded the prescribed range. Documentation did not indicate that the physician's order was updated to reflect the increased oxygen requirement. Interviews with facility staff, including the DON and Administrator, confirmed that the resident was administered oxygen above the ordered range and that the physician should have been notified to update the order. There was no documentation to show that the provider was informed when the resident's oxygen needs exceeded the prescribed parameters. The Medical Director also stated that orders should be followed as written.
Failure to Provide Scheduled Showering Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living (ADL), including bathing and personal hygiene, did not receive the scheduled assistance with showering. The resident, who had multiple significant medical diagnoses such as COPD, severe sepsis, acute chronic hypoxic respiratory failure, and colitis, was admitted to the facility and care plans indicated a need for staff assistance with bathing. The facility's shower schedule showed the resident was to receive showers twice weekly during the night shift, and the Minimum Data Set assessment confirmed the resident required supervision or assistance for showering. Record review revealed that during the resident's stay, only one shower was documented, with no evidence of additional showers or refusals. The resident's son expressed concern about the lack of showering, stating that his mother required more frequent hygiene care due to her health issues. The DON confirmed that only one shower was documented and stated that all showers or refusals should have been recorded, indicating a failure to provide and document the required ADL assistance.
Failure to Maintain Infection Control and Animal Management in Memory Care Unit
Penalty
Summary
Staff failed to maintain proper infection prevention practices in the Memory Care Unit, specifically regarding the management of two domestic cats residing in the facility. Observations revealed that one cat was seen exiting a resident's room and another was sleeping in a hallway chair. Dried cat feces were found on the floor and bedding in a resident's room, and a litter box was located behind a recliner in the family room. Staff interviews indicated uncertainty about who was responsible for cleaning the litter boxes, and inconsistent practices for cleaning up cat feces and soiled bedding were described. The CNA interviewed stated she would dispose of soiled items in a red hazard bag and sanitize the area, but was unsure about the overall cleaning protocol. Further interviews with the Director of the Memory Care Unit and the DON revealed that the cats did not currently have nail covers, and there was uncertainty about when their nails were last trimmed. The director acknowledged that a resident had been scratched by one of the cats, resulting in a change in the resident's condition. The director was unaware of the cats defecating in residents' rooms but stated that the Activities staff was responsible for cleaning the litter box. The DON confirmed that nail covers had been used in the past but were unsure if they were currently in place, and mentioned a new staff member was now available to trim the cats' nails and apply covers.
Trip Hazard from Above-Ground Sprinkler Head in Courtyard
Penalty
Summary
The facility failed to ensure the memory care unit courtyard was free from accident hazards when a lawn sprinkler head was observed protruding approximately 6 inches above the ground. During an observation, an unnamed person walking in the courtyard tripped over this sprinkler head while approaching the gate. The Administrator acknowledged awareness of the above-ground sprinkler but was not aware of any incidents resulting from it. The Maintenance Director confirmed that the sprinkler head was supposed to be recessed and not above ground, attributing its position to being frozen up.
Improper Storage and Handling of Oxygen Cannulas
Penalty
Summary
Surveyors observed multiple instances where oxygen cannulas were not properly stored or maintained in the Memory Care Unit. In one room, an unused nasal cannula connected to an oxygen concentrator was found lying on the floor underneath a pair of shoes, and a cat was seen walking across it. In the same room, another unused nasal cannula was observed on the floor next to the bed, also connected to an oxygen concentrator. In the dining/activities room, a resident was seen sitting in a wheelchair with an unbagged oxygen cannula wrapped around the back handle of the wheelchair. Interviews with staff revealed inconsistent practices and understanding regarding the proper handling and storage of oxygen cannulas. A CNA stated that cannulas found on the floor should be sanitized or replaced, while an RN was unsure if cannulas not in use should be bagged or could remain on the wheelchair. The Director of the Memory Care Unit and the DON both confirmed that cannulas should not be left on the floor and should be disposed of if found there, and that unused cannulas stored on wheelchairs should be kept in a plastic bag. These observations and interviews indicate a failure to consistently implement infection prevention and control measures related to the handling and storage of oxygen cannulas.
Failure to Administer Blood Thinner and Monitor for Stroke Symptoms
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who had a history of cerebral palsy, muscle weakness, lack of coordination, difficulty in walking, sequelae of cerebral infarction, reduced mobility, and peripheral vascular disease, was not monitored for signs and symptoms of stroke. Additionally, the resident was not treated with blood thinning medication as ordered. The resident's hospital discharge records included an order for clopidogrel, a blood thinning medication, which was not administered by the facility staff. The resident's medical records, including the Medication Administration Records and Treatment Administration Records, did not contain instructions for administering clopidogrel or monitoring for stroke symptoms. Interviews with the Medical Director, Director of Nursing, and Nurse Practitioner revealed that the order for clopidogrel was present in the hospital discharge records, but it was not transcribed or administered due to oversight. The Director of Nursing acknowledged missing the order during the post-admission review, and the Nurse Practitioner noted that the orders were unclear about the duration of the medication. The resident expressed awareness of the need for a blood thinner and reported that the facility did not provide it upon admission. The facility's Administrator and Director of Nursing confirmed that the resident's medical record lacked instructions for monitoring stroke symptoms and that the resident was not treated for his history of cerebrovascular accident. This oversight led to the identification of an Immediate Jeopardy situation, as the resident did not receive necessary medication and monitoring for his condition.
Failure to Administer Clopidogrel as Ordered
Penalty
Summary
The facility failed to administer clopidogrel, a blood-thinning medication, as ordered by the physician for a resident with a history of cerebral infarction, congestive heart failure, and peripheral vascular disease. The resident was admitted to the facility with hospital discharge orders that included clopidogrel, 75 mg daily, which was not administered from the time of admission. This oversight was confirmed through record reviews and interviews with the Medical Director, Director of Nursing, and Nurse Practitioner, all of whom acknowledged the missed order. The deficiency was identified during a review of the resident's Medication Administration Records, which showed that clopidogrel was not given from October 2025 through February 6, 2025. Interviews with facility staff revealed that the Director of Nursing missed the medication order during the verification of the resident's admission orders. The Nurse Practitioner also confirmed that the resident should have received clopidogrel as per the hospital discharge orders.
Deficient CNA Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required in-service training of at least 12 hours per year. This deficiency was identified for four CNAs (#4, #5, #6, and #7) out of five CNAs randomly reviewed. A review of the facility's employee training transcripts for the year revealed that CNA #4 completed 6.33 hours, CNA #5 completed 6.30 hours, CNA #6 completed 1.22 hours, and CNA #7 completed 1.38 hours of training. During an interview, the Director of Nursing (DON) confirmed that these CNAs did not meet the annual training requirement and acknowledged awareness of the deficiency.
Failure to Obtain Medication Consent
Penalty
Summary
The facility failed to ensure that residents or their guardians were informed about the medications they received, including the reasons, risks, and benefits, which is necessary for making informed decisions. Specifically, for one resident, there were physician's orders for buspirone, an antianxiety medication, and citalopram, an antidepressant, but the medical record lacked consent forms from the resident or responsible party for these medications. During an interview, the Director of Nursing confirmed the absence of signed consent forms for these medications, acknowledging that such documentation should be present in the resident's medical record.
Failure to Document Resident's Advance Directive Correctly
Penalty
Summary
The facility failed to ensure that a resident's current advance directive was properly documented, leading to a discrepancy between the resident's face sheet and physician orders. The face sheet indicated that the resident was Full Code, meaning they desired life-saving procedures such as CPR. However, the physician orders documented the resident's choice as Do Not Resuscitate (DNR), indicating they did not want CPR if their heart or breathing stopped. During an interview, the Director of Nursing confirmed that the resident's code status should be DNR and not Full Code. This inconsistency in documentation is likely to cause confusion and delay potentially lifesaving procedures.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, which is a federally mandated assessment instrument. The deficiency was identified for one of the three residents reviewed for assessment accuracy. The resident in question had multiple diagnoses, including cerebral palsy, muscle weakness, and peripheral vascular disease, and was prescribed clopidogrel, a blood-thinning medication, upon discharge from the hospital. However, the admission MDS did not accurately reflect the resident's active diagnoses and failed to indicate the use of antiplatelet or anticoagulant medications. During an interview, the Director of Nursing acknowledged the discrepancy between the resident's admission MDS and hospital discharge documentation.
Failure to Include Antiplatelet Medication in Baseline Care Plan
Penalty
Summary
The facility failed to create an accurate Baseline Care Plan for a resident upon their admission, which is necessary to properly care for them immediately. The resident, who was admitted with multiple diagnoses including cerebral palsy, muscle weakness, and peripheral vascular disease, had a hospital discharge order for clopidogrel, a blood-thinning medication. However, this medication was not included in the resident's Baseline Care Plan. During an interview, the Director of Nursing acknowledged that she missed the order for clopidogrel when verifying the resident's admission orders, which led to the omission of the antiplatelet medication from the Baseline Care Plan. This oversight could likely result in a decline in the resident's health due to staff not being aware of the resident's needs, potentially affecting their ability to attain or maintain their highest practical level of well-being.
Failure to Complete Staff Competency Assessments
Penalty
Summary
The facility failed to complete staff competencies for two Certified Nursing Assistants (CNAs) out of five sampled for annual training. Specifically, CNA #6 and CNA #7 did not have a competency assessment completed during the last twelve months. This was confirmed through a record review of the facility's employee competencies, which revealed the absence of these assessments. During an interview, the Director of Nursing (DON) acknowledged the lack of documentation for the competency assessments of CNA #6 and CNA #7. Additionally, the Educator stated that staff competency assessments should be completed yearly to identify necessary training, but could not confirm if all staff had undergone such assessments in the past year.
Failure to Evaluate and Document Medication Regimen Review
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications. This deficiency involved a resident under psychiatric care who was prescribed quetiapine for depression and trazodone for insomnia. The facility's consultant pharmacist recommended evaluating and considering a dose reduction for these medications during a Medication Regimen Review (MMR). However, the attending physician did not provide a clinical basis for disagreeing with the pharmacist's recommendation and did not document any actions taken to address the recommended dose reduction in the resident's medical record. Interviews with the facility's Medical Director and consultant pharmacist revealed that the attending physician, who no longer worked at the facility, was expected to consult with the resident's psychiatrist to evaluate the recommended dose reduction. The lack of consultation and documentation by the attending physician led to the resident's medication regimen not being properly evaluated, which could result in potential over-medication.
Failure to Ensure Proper Evaluation of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a resident's medication regimen was free from unnecessary medications when a hospice physician ordered a PRN antipsychotic medication without a 14-day stop date. The resident, who was under hospice care, had an order for haloperidol 2 mg every six hours as needed for agitation, with the stop date entered as indefinite. This oversight was identified during a record review and interviews with facility staff, including the Medical Director and Pharmacist Consultant. The Pharmacist Consultant recommended an evaluation of the antipsychotic medication order due to the lack of a 14-day stop date. The facility's Attending Physician acknowledged the order was entered by the hospice physician. Both the Medical Director and Pharmacist Consultant emphasized the need for the hospice physician to evaluate the resident's response to the medication and decide on the continuation or discontinuation of the order. The deficiency highlights a lapse in the proper evaluation and management of the resident's medication regimen, potentially leading to overmedication.
Failure to Date Insulin Pens and Secure Medication Carts
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of insulin glargine pens for a resident, which is a medication used to manage blood sugar levels. During an observation, it was found that three insulin glargine pens belonging to the resident were opened but not dated, contrary to the manufacturer's instructions that require opened pens to be discarded within 28 days. Nurse #12 acknowledged the oversight, stating that he should have dated the pens and discarded them within the specified timeframe. Both the Director of Nursing and the facility's pharmacist consultant confirmed the requirement for dating and discarding the pens within 28 days. Additionally, the facility did not ensure that medication carts were locked when unattended. An observation revealed that a medication cart on the 200-unit was left unlocked and unattended. Registered Nurse #1 confirmed that medication carts should be locked and secured at all times when not in use. These practices could lead to residents receiving less effective or expired medications and pose a risk of unauthorized access to medications.
Failure to Provide ADL Assistance for Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for a resident who was dependent on staff for showers. The resident, who had been admitted to the facility following a series of falls and a stay in trauma intensive care, was noted to be fully dependent on staff for personal care, including bathing. However, a review of the facility's shower logs revealed that there were no records of the resident receiving or being offered showers during September and October 2024. This lack of documentation was corroborated by the resident's daughter, who reported that despite repeated requests, her father did not receive a shower during his six-week stay at the facility. The resident's daughter further stated that her father was left in the same soiled hospital gown for a week and appeared unclean, despite the family providing clean clothes for him. The family was also informed by the staff that they were responsible for the resident's oral care, which was not provided by the facility. The Director of Nursing confirmed that there were no records indicating that the resident was offered or received a shower, highlighting a significant lapse in the facility's care provision. The resident was discharged to a family member's home, where he passed away shortly after.
Failure to Recognize and Respond to Resident's Decline
Penalty
Summary
The facility failed to provide quality care for a resident, identified as R #5, by not recognizing a change in the resident's condition for seven days. The staff did not notify the physician or the resident's Power of Attorney (POA) about the decline in the resident's health. Additionally, the facility did not assess the cause of the decline or provide necessary treatment. The resident was on hospice care with multiple serious diagnoses, including multiple sclerosis, MRSA infection, and severe sepsis with septic shock. Despite these conditions, the facility did not act promptly to address the resident's worsening state. The resident's condition was documented to have deteriorated, with signs of slow mental status, confusion, and agitation. Despite these observations, the facility did not notify the POA or hospice physician. The resident refused medications and was noted to be crying and calling for help, yet there was no indication that the POA or hospice was informed. The POA expressed a desire to remove the resident from hospice care and send her to the hospital, but the facility delayed this process. The resident's vital signs indicated a critical state, yet the facility waited 15 hours after the POA's request to send the resident to the hospital. Upon arrival at the hospital, the resident was found to be unresponsive, hypotensive, and bradypneic, requiring intubation and vasopressors. The hospital's assessment revealed significant medical issues, including metabolic acidosis and acute kidney injury. The resident's brother, who was the POA, expressed dissatisfaction with the care provided, stating that he was not kept informed of the resident's decline. The Director of Nursing (DON) acknowledged the delay in sending the resident to the hospital and the lack of communication with the POA regarding the resident's condition.
Failure to Notify POA of Resident's Decline
Penalty
Summary
The facility failed to notify the family member/Power of Attorney (POA) for a resident when the resident began to decline, consistently refused medications, and was not eating or drinking. The nursing progress notes indicated that the resident refused all medications, expressed agitation, and required assistance with drinking. Despite these significant changes in the resident's condition, there was no documentation that the staff informed the resident's brother/POA of these developments. The Director of Nursing confirmed the absence of such documentation and acknowledged that the staff should have notified the POA. The resident's brother/POA was unaware of the resident's condition until a friend informed him of the resident's poor state. The brother/POA had signed paperwork for hospice services, but he did not receive any updates from the hospice company or the facility after services began. He only learned about the resident's refusal of medications and lack of eating and drinking when contacted by a friend, prompting him to request the resident's transfer to a hospital.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Albuquerque
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Vida Llena | 0.5 mi | ★★★★★ | 11 | 0 |
| Canyon Transitional Rehabilitation Center, Llc | 0.7 mi | ★★★★★ | 36 | 0 |
| Sandia Ridge Center | 2.8 mi | ★★★★★ | 11 | 0 |
| Las Palomas Center | 3.2 mi | ★★★★★ | 14 | 6 |
| Uptown Rehabilitation Center | 3.8 mi | ★★★★★ | 1 | 0 |
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