Below 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 Falcon Heights Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
Two residents with significant cognitive and psychiatric histories, including schizoaffective disorder, dementia, bipolar disorder, traumatic brain injury, and prior aggressive behaviors, were physically abused by other residents in shared areas. In one case, a resident with expressive aphasia and severe cognitive impairment was struck multiple times in the chest and shoulder by another resident with a documented history of aggression while they waited in the dining room. In the other case, during a supervised smoking break, a cognitively intact but behaviorally aggressive resident became agitated over another resident’s leg position, then stood, grabbed the resident by the shirt, and punched him in the face multiple times, causing facial redness, while staff on site were unable to intervene in time to prevent the blows.
A resident was not protected from physical abuse by a roommate with dementia and a history of agitation and aggression. The roommate blocked the doorway, called the resident a thief, and pushed, punched, and kicked him during the altercation. The victim said he did not feel safe, and the facility substantiated the incident as abuse. Staff interviews showed some CNAs were not aware of the resident’s behavior triggers, while the DON said behavior information was expected to be available through the Kardex and care plans.
A resident in a memory care unit with severe cognitive impairments and behavioral disturbances physically abused another resident on two occasions. Despite immediate staff intervention and separation of the residents, the facility's investigations did not substantiate the incidents as abuse. The assailant's care plans lacked identification of behavior triggers and effective interventions, contributing to the incidents.
A resident with severe cognitive impairment was involved in multiple unreported incidents of potential abuse, including striking and shoving other residents. Despite staff awareness of reporting procedures, the facility failed to report these incidents to the State Agency as required by policy.
A resident with severe cognitive impairments and multiple diagnoses was involuntarily discharged to a hospital without the required physician's discharge order or proper documentation. The facility failed to include a physician's signature on the discharge notice and did not retain necessary discharge paperwork in the resident's EMR, as confirmed by the NHA.
The facility failed to maintain resident dignity for two residents. One resident, with a history of stroke and tremors, was not provided meal assistance in a dignified manner, as staff stood over her despite her preference for them to sit. Another resident, with hemiplegia, reported an LPN refused to assist with a blanket, insisting on independence. These actions did not align with the facility's dignity policy.
The facility failed to provide residents with palatable and properly prepared meals, leading to dissatisfaction among several residents. Complaints included late meal delivery, incorrect diet trays, and unappetizing food. A test tray evaluation confirmed issues with food quality, such as dryness and blandness. The dietary account director admitted to overcooked and watery food items, highlighting a deficiency in food preparation and service.
The facility failed to maintain sanitary conditions in the kitchen by not accurately testing the chemical sanitizer solution's concentration in the dishwasher and sanitizer buckets. Observations showed inadequate testing frequency and low sanitizer concentration levels, contrary to the manufacturer's recommendations. Staff interviews revealed a lack of routine checks and documentation, leading to unsanitary conditions.
The facility failed to honor residents' right to choose their attending physician when it changed medical provider groups without informing or obtaining consent from residents. Interviews with several residents revealed they were unaware of the change and had not been consulted. The facility's administration confirmed the change was a corporate decision, and no meetings or letters were provided to inform residents or obtain their consent.
The facility failed to maintain a safe and homelike environment, with several room doors being difficult to open and close due to misalignment, and damaged floors not being repaired. Observations showed issues with room doors and missing flooring in the dining room. Interviews with two residents and a CNA confirmed ongoing problems with door operability, which had been reported to the maintenance supervisor. The NHA and MS acknowledged the issue, with plans to replace the doors.
The facility failed to maintain a safe environment for residents, particularly in smoking practices and medication management. A resident was left with medication at her bedside without a proper self-administration assessment, and another resident reported burning her fingers while smoking unsupervised. Additionally, two residents had medications at their bedside without physician orders or assessments, raising concerns about unauthorized access. Staff interviews revealed a lack of adherence to policies, contributing to these deficiencies.
The facility failed to properly store and label medications, with observations revealing expired medications and an undated insulin pen across several medication carts and a storage room. Staff interviews indicated a lack of adherence to medication management protocols.
The facility failed to ensure proper hand hygiene practices among nursing and housekeeping staff, leading to deficiencies in infection prevention. Nurses did not perform hand hygiene during medication administration, and a housekeeper did not change gloves or perform hand hygiene between cleaning tasks. These actions were confirmed by staff interviews and observations.
The facility failed to ensure adequate ventilation in three resident shower rooms, as the exhaust fans were not functioning effectively, leading to strong odors and humidity. The maintenance supervisor was unaware of the issue due to the fans not being included in the maintenance tracking system.
A resident with multiple health issues experienced a deterioration in condition, but the on-call physician did not return calls for treatment orders. The retired medical director was contacted and ordered a chest x-ray, leading to the resident being sent to the ER. The facility's change in medical groups without informing residents contributed to delays in care, as the new group did not return calls after hours, causing frustration among staff.
The facility failed to protect two residents from physical abuse by each other on two occasions. The first incident was deemed accidental, but a witness confirmed one resident hit the other. The second incident involved a verbal exchange and physical retaliation, with no documentation on whether it was substantiated. The facility did not update care plans or implement interventions to prevent further altercations, contributing to the deficiency.
Two residents in the facility did not receive adequate assistance with activities of daily living. One resident, with multiple health conditions, did not receive showers according to his preferences, and his care plan lacked documentation of these preferences. Another resident, also with significant health issues, did not receive proper fingernail care, as her nails were observed to be long and soiled. Staff interviews revealed a lack of accountability and documentation, and the DON acknowledged ongoing issues despite previous audits.
A resident with multiple medical conditions was not provided with adequate activities as per their care plan. Despite preferences for music and religious activities, the resident was often left with only a radio playing, which was not a care-planned activity. The facility failed to consistently provide one-to-one visits and group activity participation, with staff marking the resident as unavailable rather than documenting refusals. Interviews revealed a lack of adherence to the care plan and incorrect assumptions about the resident's television functionality.
A resident with chronic pain conditions did not receive a prescribed pain-relieving cream as ordered, despite the MAR indicating otherwise. The resident, who was alert and oriented, reported not receiving the medication, and an LPN admitted to inaccurately marking the MAR. The DON confirmed the medication should have been administered as ordered and expressed concern about other potential medication administration errors.
A medication error rate of 8% was observed in an LTC facility, exceeding the acceptable threshold of 5%. An LPN administered only one tablet of Lexapro instead of two as prescribed, and levothyroxine sodium was given after the resident had eaten, contrary to the requirement for it to be taken on an empty stomach. The DON confirmed the errors and the need for adherence to physician orders.
Failure to Prevent Resident-on-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by other residents, despite existing policies intended to prohibit and prevent abuse. The facility’s Abuse, Neglect, and Exploitation policy required identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, as well as deployment of sufficient, trained staff and attention to environmental factors that could make abuse more likely. In practice, residents with known behavioral histories and cognitive impairments were in shared environments such as the dining room and smoking area where altercations occurred. The report documents that these incidents were substantiated as physical abuse. In the first incident, an altercation occurred in the dining room between Resident #7, who had schizoaffective disorder, depression, severe cognitive impairment, expressive aphasia, and a history of being both an aggressor and a recipient of physical aggression, and Resident #9, who had stroke with left-sided paralysis, bipolar disorder, depression, anxiety, and a documented history of taking items from staff, swinging at staff, and throwing objects at other residents. Resident #7 had verbal behavioral symptoms toward others and a behavior of agitating other residents by pointing and muttering. Resident #9 had a history of behavioral outbursts during psychotic episodes. While residents were in the dining room waiting for dinner, a witness reported that Resident #9 hit Resident #7 several times in the chest and shoulder. Resident #7 was unable to verbally report the incident due to expressive aphasia. Prior to this altercation, both residents had care plans identifying behavioral issues, but the interventions in place at the time did not prevent the physical abuse. Resident #7’s mood and behavior care plan, initiated earlier, identified her as both an aggressor and a recipient of physical aggression, and Resident #9’s care plan documented prior physical aggression toward staff and other residents. The interdisciplinary team later attributed the altercation to impulsivity and behavioral histories, but at the time of the event, Resident #7 and Resident #9 were together in the dining room without effective preventive measures that would have kept Resident #7 free from physical abuse. In the second incident, a physical altercation occurred between Resident #10 and Resident #11 during a supervised smoking break. Resident #11 had a history of traumatic brain injury, Parkinson’s disease, dementia, schizophrenia, depression, and anxiety, with severe cognitive impairment and documented verbal behaviors toward others. His care plans noted verbal aggression, triggers such as others staring at him and waiting for cigarettes, and difficulty understanding others due to cognitive and communication deficits. Resident #10 had mood disorder, depression, anxiety, personality disorder, and a documented history of anxiety with verbal aggression and physical aggression toward other residents, including a care plan specifically addressing physical aggression. During the smoking break, Resident #10 became agitated when Resident #11’s legs were in close proximity. Resident #10 stood up from his wheelchair and attempted to swing at Resident #11, who responded by placing his foot against Resident #10’s chest to create distance. Resident #10 then pulled himself closer, grabbed Resident #11 by the shirt, and punched him in the face near his right eye multiple times. A staff member was present supervising the smoking break but was unable to intervene in time to prevent the blows. Resident #11 was later found to have a small red area on the right side of his face and redness on his right cheek and jaw. Both residents had known histories of aggression and impulsivity, and the interdisciplinary team later attributed the altercation to a misunderstanding of personal space, but at the time of the event, the supervision and existing behavioral interventions did not prevent Resident #11 from being physically abused by Resident #10.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure one resident was kept free from physical abuse by another resident. The abuse policy stated the facility was responsible for protecting residents from abuse, including resident-to-resident altercations. The incident involved two residents with cognitive impairment who were roommates at the time of the event. The facility investigation documented that one resident accused his roommate of stealing from him, blocked the doorway with his body, called the other resident a thief, and pushed him. The victim resident told the ADON that he did not feel safe and said the other resident had punched and kicked during the interaction and had tried to kick him out of the room the day before. The other resident stated that both residents had hands on each other and said the victim started the fight. The investigation substantiated the incident as abuse. The victim resident had vascular dementia, a BIMS score of 12, and required a walker with supervision to touching assistance for ADLs. The resident identified as the aggressor had unspecified dementia with agitation, altered mental status, and communication deficits, with a BIMS score of 5. His care plans documented a history of physical aggression toward other residents, wandering into other residents' rooms, frustration, and agitation, with interventions including redirection, food or drink, and 15-minute checks. Staff interviews showed some CNAs were not aware of specific behavior triggers, while the DON stated staff were expected to use the Kardex and care plans for triggers and interventions and that changes were discussed in IDT meetings.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident on two separate occasions. The first incident occurred when a resident pushed another resident to the floor, which was witnessed by a certified nurse aide. Despite the immediate response by staff to separate the residents and assess them for injuries, the facility's investigation did not substantiate the occurrence as abuse, even though the physical act of pushing was confirmed. In the second incident, a nurse witnessed the same resident approach the victim with agitation and push them in the face. Again, the residents were separated, and no injuries were reported. The assailant was placed on one-to-one staff observation and later transported to the hospital for evaluation, where a new antipsychotic medication was prescribed. Despite these actions, the facility's investigation once more failed to substantiate the incident as abuse. The assailant, who resided in the memory care unit, had a history of severe cognitive impairments and behavioral disturbances, including physical aggression. The care plans for the assailant did not adequately identify behavior triggers or effective interventions, which contributed to the incidents. The victim, also with severe cognitive impairments, was not injured in the altercations but was not adequately protected from the aggressive behavior of the other resident.
Failure to Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency as required by state law. Specifically, the facility did not report an allegation of abuse involving a resident who had severe cognitive impairment and a history of hallucinations, delusions, and verbal behaviors directed at others. The resident was involved in multiple incidents where he struck another resident, shoved a resident in a wheelchair, and grabbed another resident's arm in an aggressive manner. These incidents were documented in the resident's electronic medical record but were not reported to the State Agency. Interviews with facility staff, including a CNA and an RN, revealed that they were aware of the procedures for reporting abuse and would report such incidents to the Director of Nursing or the Nursing Home Administrator. However, the Nursing Home Administrator admitted that the documented incidents involving the resident were not reported to the State Agency. The facility's policy required that all alleged violations involving abuse be reported immediately, but this was not adhered to in the case of the resident's actions.
Failure to Provide Proper Discharge Documentation for a Resident
Penalty
Summary
The facility failed to provide a written discharge notice, including a physician's discharge order, for one of the residents, identified as Resident #5, out of a sample of 13. The discharge was facility-initiated and involuntary, yet the necessary documentation, such as a physician's signature on the Nursing Home Notice of Involuntary Transfer or Discharge, was missing. Additionally, there was no attached written physician's order, which is a requirement when a resident is discharged under such circumstances. Resident #5, who was over 65 years old and had severe cognitive impairments, was admitted with diagnoses including Alzheimer's disease, chronic kidney disease, severe vascular dementia, and type 2 diabetes mellitus. The resident exhibited severe cognitive impairments, hallucinations, delusions, and aggressive verbal behaviors. On the day of discharge, the resident was involved in multiple altercations and was ultimately sent to the hospital due to increased agitation and aggressive behavior. The facility's documentation was incomplete, as there were no physician discharge orders, discharge paperwork, or transfer forms (e-interact) available in the resident's electronic medical record. The nursing home administrator confirmed the absence of these documents during an interview. The facility's policy required these documents to be completed and retained, but this was not adhered to in the case of Resident #5.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to promote and maintain resident dignity for two residents, leading to deficiencies in providing care in a dignified, respectful, and individualized manner. Resident #35, who has a history of cerebral infarction, dysphagia, bipolar disorder, PTSD, and ataxia, was not provided meal assistance in a dignified manner. Observations revealed that staff, including a CNA and an OT, stood over the resident while assisting with meals, despite the availability of a folding chair in the room. The resident expressed feeling belittled when staff stood over her, as she preferred them to sit at her level during meal assistance. The care plan indicated the resident required specific adaptive utensils due to tremors, yet staff did not consistently provide the dignified dining experience outlined in the facility's policy. Resident #51, who has hemiplegia following a cerebral infarction, reported being treated without dignity and respect when asking for assistance. The resident, who is cognitively intact, recounted an incident where an LPN refused to help cover his feet with a blanket, insisting he could do it himself and choosing to watch instead. The nursing progress note corroborated this account, documenting the LPN's refusal to assist and her insistence on the resident's independence. The NHA acknowledged that the LPN's behavior was inappropriate and that all residents should be treated with dignity and respect, regardless of their level of independence. These incidents highlight the facility's failure to adhere to its dignity policy, which emphasizes providing care that enhances residents' well-being and self-esteem. The staff's actions in both cases did not align with the policy's requirement to support residents in exercising their rights and ensuring a dignified experience. The deficiencies were identified through observations, resident interviews, and staff interviews, revealing a gap between the facility's stated policies and the actual care provided.
Deficiency in Food Quality and Service
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable in taste, texture, appearance, and temperature. Multiple residents reported dissatisfaction with the meals, citing issues such as late delivery, incorrect diet trays, and unappetizing food. One resident mentioned receiving cold hamburgers and hot dogs, while another noted that the food was often served late and lacked condiments. A resident who attended dialysis appointments reported that the kitchen staff frequently forgot to prepare his dinner, leaving him with inadequate food options, which resulted in him feeling hungry and unwell. Additionally, residents complained about the bland and flavorless nature of the food and drinks. A test tray evaluation by surveyors confirmed the residents' complaints, revealing that the food was dry, bland, and watery. The dietary account director acknowledged that the encrusted pork loin was overcooked and that the gravy was watery due to being prepared in haste. The regional dietary manager emphasized the importance of ensuring the right food texture and taste to prevent residents from not eating their meals. The nursing home administrator indicated that more education would be provided to the kitchen staff, but the report focuses on the deficiency in food preparation and service that led to resident dissatisfaction.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to ensure that food items were stored and served under sanitary conditions in the main kitchen. Specifically, the staff did not correctly and accurately test the chemical sanitizer solution's concentration in the dishwasher, three sink compartments, and sanitizer buckets. Observations revealed that the dishwasher's chemical concentration was not consistently tested throughout the day, as required by the manufacturer's recommendations. The dishwasher initially registered a concentration of 10 ppm, which was below the required 150 ppm, indicating that the machine needed to be primed. Additionally, the sanitizer solution in the red and green buckets used for cleaning equipment and surfaces was also found to be at an inadequate concentration of 10 ppm. Interviews with the dietary aide and dietary account manager revealed that the staff did not routinely check the chemical concentration of the sanitizer when filling the buckets. The kitchen had an automatic solution dispenser, but the staff did not test the solution each time they filled the buckets, nor was there a log for documenting the test strip results for the red sanitizing buckets. The facility's policy required that temperature and sanitizer concentration logs be completed as appropriate, but the logs were only completed once a day, contrary to the manufacturer's recommendation of testing at least three times a day. This lack of adherence to proper testing protocols led to the deficiency in maintaining sanitary conditions in the kitchen.
Failure to Honor Residents' Right to Choose Attending Physician
Penalty
Summary
The facility failed to honor the residents' right to choose their attending physician when it changed medical provider groups. This deficiency was identified through interviews and record reviews, revealing that residents across five hallways were not informed or given the opportunity to consent to the change in their primary care provider (PCP). The facility's policy, which mandates informing residents in writing about their attending physician during admission, upon changes, and upon request, was not followed. Interviews with several cognitively intact residents indicated that they were unaware of the change and had not been consulted or informed about the new physician assigned to them. The facility's administration, including the Nursing Home Administrator (NHA) and the Regional Clinical Consultant (RCC), confirmed that the change in the medical provider group was a corporate decision made on June 1, 2024, and that they were not given a choice in the matter. The NHA admitted that no meetings or letters were provided to inform residents or obtain their consent. Additionally, a group interview with alert and oriented residents corroborated that they were not informed about the change in medical provider groups, nor were they asked for their permission. The facility was unable to provide documentation proving that residents and their responsible parties had been informed or that consent was obtained for the change in physicians.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents, staff, and the public on four of five units. Specifically, the facility did not provide necessary maintenance services to ensure that resident room doors were easily operable and that damaged floors were repaired. Observations revealed that several room doors were difficult to open and close due to misalignment, and there were issues with missing and chipped paint on doors and door frames. Additionally, the main dining room had missing flooring by the entrance. Interviews with residents and staff highlighted ongoing issues with the room doors. Two residents reported that their bedroom doors had been difficult to open and close for several months, and despite reporting these issues to staff, no corrective action had been taken. A CNA confirmed that most room doors required significant effort to open and close, and these issues had been reported to the maintenance supervisor. The nursing home administrator and maintenance supervisor acknowledged the problem, noting that some doors had been replaced and others were scheduled for replacement.
Deficiencies in Resident Safety and Medication Management
Penalty
Summary
The facility failed to ensure a safe environment for residents, particularly in relation to smoking practices and medication administration. Resident #35, who was cognitively intact but required assistance with personal hygiene and dressing, was observed with medication left at her bedside without a proper self-administration assessment. Despite a physician's order allowing her to keep Creon at her bedside being discontinued, the medication was still left unattended, posing a risk. Additionally, Resident #35 reported burning her fingers while smoking unsupervised, contrary to the facility's policy requiring direct supervision for unsafe smokers. Resident #43, who was also cognitively intact, was found with multiple medications at her bedside, including eye drops, nasal spray, and dairy relief pills, without a physician's order or self-administration assessment. During an interview, Resident #43 mentioned that other residents, including one with severe cognitive impairment, frequently entered her room, raising concerns about the accessibility of medications to unauthorized individuals. The facility's failure to conduct proper assessments and secure medications contributed to this deficiency. Similarly, Resident #66, who was independent with activities of daily living, had Aspercreme Lidocaine spray at her bedside without a physician's order or self-administration assessment. The facility did not have a system in place to ensure that medications kept at the bedside were authorized and secure, as evidenced by the lack of lock boxes and comprehensive care plans for self-administration. Interviews with staff, including the DON and LPN, revealed a lack of awareness and adherence to policies regarding medication administration and supervision, further highlighting the facility's deficiencies in maintaining a safe environment.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and labeled according to professional standards. During observations, it was found that three out of five medication carts and one of two medication storage rooms contained improperly labeled or expired medications. Specifically, an open Tresiba FlexTouch insulin pen was not labeled with the date it was opened, and several expired medications, including liquid haloperidol, lorazepam vials, Tylenol, and a vitamin supplement, were found in the medication carts and storage room. Interviews with staff revealed a lack of awareness and adherence to proper medication management protocols. An LPN acknowledged that the insulin pen should have been dated upon opening but was unsure of the duration it remained effective. Another LPN admitted to checking for expired medications but failed to remove them from the cart. The DON confirmed that expired medications and supplies should have been removed and that the insulin pen should have been dated when opened.
Inadequate Hand Hygiene Practices in Nursing and Housekeeping
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of communicable diseases and infections in three of five hallways. Specifically, nursing staff did not perform proper hand hygiene during medication administration. On two separate occasions, a registered nurse and a licensed practical nurse were observed preparing and administering medications to multiple residents without performing hand hygiene before or between each resident. Both nurses acknowledged during interviews that they should have performed hand hygiene between preparing medications for each resident, as confirmed by the director of nursing. Additionally, the facility's housekeeping staff did not adhere to proper hand hygiene protocols while cleaning resident rooms. A housekeeper was observed cleaning multiple rooms without changing gloves or performing hand hygiene between tasks, such as mopping and sweeping. The infection preventionist confirmed that housekeeping staff should remove gloves, perform hand hygiene, and apply new gloves when moving from room to room and after cleaning bathrooms. These lapses in hand hygiene practices were identified as deficiencies in the facility's infection prevention and control program.
Inadequate Ventilation in Resident Shower Rooms
Penalty
Summary
The facility failed to provide adequate ventilation in three of four resident shower rooms, as observed during inspections. The exhaust fans in the shower rooms on the 300, 400, and 600 halls were not functioning effectively, as evidenced by the lack of audible sound and the presence of a strong urine odor and humidity in the rooms. The maintenance supervisor was unaware of the malfunctioning exhaust fans because they had not been included in the system used to track maintenance and repairs. The nursing home administrator acknowledged that the exhaust fans should be in good working condition to eliminate odors in the resident's shower rooms.
Failure to Provide Timely Medical Care
Penalty
Summary
The facility failed to provide treatment and services in accordance with professional standards of practice for a resident who experienced a change in condition. The resident, who was 77 years old and had multiple diagnoses including chronic obstructive pulmonary disease, pulmonary hypertension, and heart failure, experienced a deterioration in condition. Despite the nurse's attempts to contact the on-call physician twice, leaving extensive messages, the physician did not return the calls. Consequently, the retired medical director was contacted, who ordered a chest x-ray and advised sending the resident to the emergency room. The resident was diagnosed with acute on chronic heart failure, pneumonia, chronic obstructive pulmonary disease, chronic anemia, and renal insufficiency during hospitalization. The retired medical director noted that the standard of care would require a physician visit within 24 to 48 hours after hospitalization, but the resident was not seen for more than 10 days after the initial change of condition. The facility's decision to change medical groups without informing or obtaining consent from residents or their responsible parties contributed to the delay in care. Interviews with the Director of Nursing (DON) and the retired medical director revealed that the new medical group did not return calls overnight or on weekends, leading to frustration among staff. The DON directed nurses to contact the retired medical director if they did not receive a callback within 15 minutes. The retired medical director expressed discomfort in treating the resident over the phone since she was not his patient, highlighting the lack of communication and coordination in the facility's medical care provision.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by each other on two separate occasions. The first incident occurred on May 3, 2024, when a physical altercation between the two residents was reported. Although the incident was deemed accidental and unsubstantiated, a witness confirmed seeing one resident hit the other. The facility's response included separating the residents, assessing them for injuries, and placing them on 15-minute checks, but no injuries were noted. The second incident took place on July 19, 2024, involving the same two residents. This time, a staff witness reported that one resident kicked the other's chair, leading to a verbal exchange and physical retaliation. Again, the residents were separated and assessed for injuries, with no injuries found. However, the facility did not document whether this incident was substantiated, and the care plans for both residents were not updated to include interventions to prevent further altercations. Resident #70, who was cognitively intact, admitted to hitting Resident #28 on purpose during the first incident due to a confrontation. Resident #28, who had moderate cognitive impairments and a history of verbal aggression, did not remember the incidents. The facility's failure to update care plans and implement person-centered interventions after these incidents contributed to the deficiency, as the residents continued to have altercations without adequate preventive measures in place.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, specifically in the areas of showering and fingernail care. Resident #65, who has diagnoses including chronic obstructive pulmonary disease, Parkinson's disease, rheumatoid arthritis, and dementia, did not receive showers according to his preferences. Despite requiring substantial to maximal assistance with bathing, the resident's care plan did not document his shower preferences, and he received significantly fewer showers than scheduled over several months. Resident #180, diagnosed with Alzheimer's disease, dementia, hemiplegia, and other conditions, did not receive proper fingernail care. Observations revealed that her fingernails were long, discolored, and soiled, with a dark substance under several nails. Despite being dependent on staff for personal hygiene, the facility's records showed that nail care was not provided on multiple occasions throughout July 2024. Interviews with staff, including CNAs and LPNs, highlighted a lack of accountability and documentation regarding the provision of showers and nail care. The Director of Nursing acknowledged the issue, noting that a previous audit had identified similar deficiencies, but the problem persisted. The facility's policies required documentation of showers and nail care, but these were not consistently followed, leading to the deficiencies observed.
Failure to Provide Adequate Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the needs and interests of a resident, identified as Resident #12, who was one of six residents reviewed for activities. Resident #12, a 75-year-old with multiple medical conditions including hemiplegia, aphasia, Parkinson's disease, Alzheimer's disease, and multiple sclerosis, was dependent on staff for all activities of daily living. His care plan indicated preferences for listening to music and participating in religious activities, yet observations revealed he was often left in his room with only the radio playing, which was not listed as a care-planned activity. The activity care plan for Resident #12, revised in May 2024, specified that he should receive one-to-one visits with activity staff two to three times per week and participate in group activities twice a week as desired and tolerated. However, documentation showed that these one-to-one visits were inconsistently provided, with only a few visits recorded each month and no documented refusals by the resident. Additionally, Resident #12 did not attend any group activities from mid-June to the end of July 2024, with staff noting he was unavailable rather than documenting any refusals. Interviews with staff, including the Activity Director and a Certified Nurse Aide, revealed a lack of adherence to the care plan. The Activity Director acknowledged that the activity department was not meeting the resident's activity goals and had assumed the resident's television was not working, which was later found to be incorrect. The Activity Assistant noted that Resident #12 was marked as unavailable for group activities due to being in bed, despite the care plan indicating he should be offered opportunities to observe and listen to group activities. The Nursing Home Administrator confirmed that the care plan should reflect the resident's needs and that documentation should accurately record visits or refusals.
Failure to Administer Pain Management Medication
Penalty
Summary
The facility failed to manage pain for a resident in accordance with professional standards of practice and the resident's care plan. The resident, who was cognitively intact and had a history of chronic kidney disease, PTSD, major depressive disorder, anxiety disorder, low back pain, and restless leg syndrome, reported not receiving a prescribed pain-relieving cream. Despite the medication administration record (MAR) indicating that the Biofreeze gel was administered as ordered, the resident stated she had not received it, which was corroborated by her alert and oriented status. The deficiency was further highlighted during staff interviews. An LPN admitted to not remembering if the medication was administered and acknowledged that the MAR was inaccurately marked as if the medication had been given. The Director of Nursing confirmed that medications should be administered as ordered and not signed off if not given. The DON expressed concern about the potential for other medications not being administered as documented, indicating a broader issue with medication administration practices.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 8% during a medication administration observation. This deficiency was identified through the observation of a licensed practical nurse (LPN) who made two errors out of 25 opportunities. The first error involved the administration of Lexapro to a resident. The physician's order was for two 5 mg tablets of Lexapro to be given once daily, but the LPN initially administered only one tablet. Upon realizing the mistake, the LPN corrected it by administering the second tablet. The second error involved the administration of levothyroxine sodium. The resident had a physician's order for 150 mcg of levothyroxine sodium to be administered in the morning on an empty stomach. However, the LPN administered the medication 89 minutes after the scheduled time and after the resident had already eaten breakfast. The Director of Nursing confirmed that levothyroxine sodium should be administered on an empty stomach and that medications should be given according to the physician's order.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 103 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Colorado Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fountain View Rehabilitation And Nursing Llc | 0.8 mi | ★★★★★ | 2 | 0 |
| Life Care Center Of Colorado Springs | 1.6 mi | ★★★★★ | 5 | 1 |
| Advanced Health Care Of Colorado Springs | 1.7 mi | ★★★★★ | 0 | 0 |
| Mountain View Post Acute | 1.8 mi | ★★★★★ | 25 | 0 |
| Medallion Post Acute Rehabilitation | 2.3 mi | ★★★★★ | 0 | 0 |
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