Bear Canyon Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Bear Canyon Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF684Feb 10, 2025

  Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #42) of 3 (R #31, #42 and #58) residents when they failed to monitor R #42 for signs and symptoms of stroke and to treat R #42 with blood thinning medication as ordered. This deficient practice is likely to result in residents experiencing worsened conditions or death. The findings are: A. Record review of R #42's face sheet revealed an admitted [DATE] and included 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… […]

• Immediate jeopardy, patternF760Feb 10, 2025

  Based on record review and interview, the facility failed to administer clopidogrel (blood thinning medication used to prevent heart attacks and strokes in persons with heart disease, recent stroke, or blood circulation disease) as ordered by the physician for 1 (R #42) of 3 (R #31, #42 and #58) residents reviewed for medications. This deficient practice is likely to result in a resident failing to obtain maximum wellness or suffer prolonged illness. The findings are: Cross Reference findings from F684. A. […]

• Immediate jeopardy, isolatedF686Jan 25, 2024

  Based on record review and interview, the facility failed to: 1. Provide oversight of shower sheets to identify wounds, 2. Accurately document new skin impairments on Skin Checks, 3. Update and implement new preventative measures, treatment, and orders when new skin impairments were identified for 1 (R #1) of 3 (R #1, 2, and 3) residents reviewed for pressure wound injuries. This deficient practice could like result in new pressure injuries, pain, or significant decline in health status. The findings are: A. […]

• Immediate jeopardy, isolatedF689Oct 13, 2023

  Based on observation, interview and record review, the facility failed to provide the required supervision for 1 (R #74) of 3 (R # 9, 74, and 78) residents reviewed when R #74 ate food from another resident's plate that was not within his ordered diet texture. This deficient practice could likely result in R #74 choking, needing to have the Heimlich maneuver (procedure for dislodging an obstruction from a person's windpipe) performed on him, be resuscitated (revived from unconsciousness), suctioned (removal of food) and could potentially cause death if this resident is not closely monitored by staff. The findings are: A. On [DATE] at 8:19 am during a random observation, breakfast was served on the 100 unit and two residents sat at a table. […]

• Immediate jeopardy, isolatedF684Sep 2, 2021

  Record review of an intake for complaint survey #NM revealed that the family had concerns about their family member [R #135] oxygen saturation being too low on 06/05/21. His oxygen saturation was checked and it was 48% [the amount of oxygen traveling through your body] The nurse was notified of this but told the family that if residents oxygen was at 48% he would be dead. No further action was taken. On 08/11/21 at 9:30 am during an interview with Certified Nursing Assistant [CNA] #7, she stated that she worked on 06/05/21 and checked the residents vitals during her morning rounds. She stated that residents oxygen level was 48%. She then checked it on a different oximeter [monitors blood oxygen saturation] and got the same reading of 48%. […]