Falcon Lake Nursing Home, LLC

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was permitted to remain in the facility and not transfer or discharge the resident from the facility for 1 of 5 residents (Resident #1) reviewed for discharge requirements. The facility failed to ensure Resident #1 was given a discharge date 30 days after being given a 30-day discharge notice on 03/06/26. The facility failed to readmit Resident #1 after he was discharged from the hospital prior to the 30th day after his 30-day discharge notice. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the contents of the discharge notice included the reason for transfer or discharge, the effective date of transfer or discharge, the location to which the resident was transferred or discharged , a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 3 residents reviewed for discharge notices. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #1) of 3 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected inappropriate behaviors such as inappropriate comments, taking facility/staff items, playing music loudly, and recording with his phone. This failure could place residents at risk of not receiving appropriate interventions and care to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 wound care cart and 1 of 2 (400 hall) medication carts reviewed for storage of drugs. The facility failed to ensure LVN A's 400 hall medication cart and the wound care cart located by the nurse station were locked when not in use. This deficient practice could affect residents who have medications on the nurse's medication cart and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 2 of 5 residents (Resident #2 and Resident #3) reviewed for resident rights. 1. The facility failed to place a privacy cover over Resident #2's catheter bag while she was in bed at 10:30 AM on 08/26/25. 2. The facility failed to place a privacy cover over Resident #3's catheter bag while she was in bed at 11:20 AM on 08/26/25. These failures could result in psychosocial harm to the residents, including feelings of shame and embarrassment and a loss of dignity.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and were knowledgeable about the resident's status, needs, strengths, and areas of decline for 1 (Resident #2) of 6 residents reviewed for assessments. The facility failed to include Resident #2's use of bed rails in both her quarterly MDS dated [DATE] and her significant change MDS assessment dated [DATE]. These failures could result in residents in the facility not being provided with the necessary care or services or implementation of personalized care plans developed to address their specific needs.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure residents comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including the comprehensive, quarterly, and significant change assessments. The facility failed to update Resident #2's care plan to include the use of full bed rails on 07/30/25 when her quarterly MDS assessment was completed and on 08/20/25 when a significant change MDS assessment was completed. These failures could place residents in the facility at risk of not being provided with the necessary care or services or implementation of personalized care plans developed to address their specific needs. Record review of Resident #2's admission record reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with most recent admission on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #2) of three residents reviewed for urinary catheters. Resident #2's urinary catheter tubing did not have an unobstructed urine flow, and the collection bag was not below Resident #2's bladder at all times. This failure places residents with urinary catheters at risk for urinary tract infections. Record review of Resident #2's admission record reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with most recent admission on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (Resident #14) reviewed for respiratory care. The facility failed to ensure Resident #14's oxygen tubing was stored off the floor and in a bag when not in use at 11:09 AM on 08/26/25. This failure placed residents at an increased risk of infection leading to a decline in health.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1unit refrigerators reviewed for storage, preparation and sanitation. -The facility failed to ensure food items in the facility kitchen refrigerator were labeled and dated. -These failures could place residents at risk for complications from food contamination.

Inspectors wroteBased on observation and interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #3 and Resident #27) of 5 residents reviewed for infection control.1. The DON, LVN C, and CNA D did not wash their hands before and after performing wound care for Resident #3.2. The DON did not pat dry wound while performing wound care for Resident #3.3. LVN C and CNA D did not wash their hands after performing incontinent care for Resident #3.4. The facility failed to ensure CNA D did not grab Resident #27's cup and bowl by the rim with her bare hands, contaminating the tops of the rims, during the lunch meal serving process. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 5 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded in the MDS for falls on 6/1/25 and 6/18/25. This failure could place residents at risk of receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 Residents (Resident #2) reviewed for medical records accuracy, in that: Resident #2's February 2025 Monitoring Administration Records documentation was incomplete and inaccurate. Staff inaccurately documented and did not sign off on the monitoring of Resident #2's wander guard. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1of 2 unit (unit 1) nutrition refrigerators reviewed for sanitation. The facility failed to maintain the kitchen freezer that had a large section of ice build-up in it. The facility failed to provide clean coffee cups for the resident's use. The facility failed to ensure the nutrition room refrigerator had labeled and dated items in them. The facility failed to ensure the nutrition room did not have expired items. The facility failed to ensure the nutrition room snack tray items were labeled, dated, and refrigerated. The facility failed to ensure the freezer temperature logs for the unit refrigerator were documented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 3 residents (Resident #3) reviewed for infection control, in that LVN A failed to wash her hands, change gloves, or sanitize her hands while providing peg tube care on Resident #3. LVN A failed to follow enhanced barrier precautions for an indwelling medical device (PEG tube). This failure could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one laundry reviewed for environment. The facility failed to ensure the doors in the laundry would open and close safely and had functioning doorknobs. The facility failed to ensure the washing machine in the laundry was not leaking water into a basin and attracting mosquitoes. The facility failed to ensure the walls in the storeroom inside the laundry did not have dark patches showing through the paint. These failures could place residents at risk for diminished quality of life due to the lack of a well kept environment.

Inspectors wroteBased on interview and record review the facility failed to ensure all irregularities reviewed/identified by the licensed pharmacist were followed for 1 (Resident #12) of 6 residents reviewed for drug regimen review, in that: The facility failed to address Seroquel (antipsychotic) being given to a resident with diagnosis of dementia. The facility failed to follow the consultant pharmacist and physician's recommendation for the gradual dose reduction of Seroquel 25mg PO one time a day. This deficient practice could place residents at risk of receiving unnecessary medications and dosages.

Inspectors wroteBased on observation, interview, and record review the facility failed to store and prepare food in a sanitary manner, in that: 1) Undated and unlabeled food were in the refrigerator and freezer. 2) Frozen food items were stored on the floor in the freezer. These failures could place residents who were served meals from the facility's kitchen at risk for food borne illness.