Falcon Heights Rehabilitation and Nursing LLC

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Rights Deficiencies

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Provide properly protected cooking facilities.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Environmental Deficiencies

Have enough outside ventilation via a window or mechanical ventilation, or both.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Services Deficiencies

Meet other general requirements that are deficient.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Resident Rights Deficiencies

Honor the resident's right to choose his or her attending physician.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

A complaint survey, prompted by #CO38781, #CO38892, Incident #39010, Incident #39011 and Incident #39068 was conducted on 1/30/25 to 2/3/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure one (#2) of six residents investigated for abuse out of seven sample residents were kept free from physical abuse. Specifically, the facility failed to protect Resident #2 from two physical abuse altercations by Resident #3. Findings include: I. Facility policy and procedure The Abuse policy, revised on 6/11/24, was provided by the nursing home administrator (NHA) on 1/30/25 at 2:42 p.m. The policy read in pertinent part, "Every resident has the right to be free from abuse. All occurrences of resident abuse shall be promptly reported to the abuse coordinator for investigation. "The facility will ensure that all residents are protected during and after abuse investigations by:-Responding immediately to protect the alleged victim;-Increasing supervision of the alleged victim and the other residents as indicated; and,-Providing emotional support to the resident during and after the investigation. "Residents with aggressive or abusive behavior shall have their care plans include approaches to reduce or eliminate risk for abuse." II. Incidents of physical abuse towards Resident #2 by Resident #3 A. Facility investigation of the altercation on 1/7/25The 1/7/25 facility occurrence investigation was provided by the NHA on 1/30/25 at 1:15 p.m. The investigation documented that at 6:51 p.m., certified nurse aide (CNA) #1 heard Resident #3 yelling at Resident #2 to get away from her. The nurse responded immediately and discovered Resident #3 pushed Resident #2 to the floor. The nurse completed assessments on both residents, and no injuries were apparent. Resident #3 was redirected by staff and the residents were separated immediately. The family, the physician and the administration were notified of the occurrence. Resident #2 recalled that she fell, and the investigation documented that neither resident recalled the physical occurrence. Resident #3 was placed on frequent monitoring for behavioral changes and redirection. The faci..