Falcon Point Post Acute

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, psychosocial well-being of each resident, encouraging both independences and interaction in the community for 1 of 3 (Resident #29) residents and 1 of 3 (Unit A) units reviewed for activities .1. The facility failed to ensure residents in Unit A had activities provided that followed the facility schedule on 03/24/2026 at 10:30 AM and 03/27/2026 at 10:30 AM and 2:00 PM. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 20% based on 9 errors out of 45 opportunities of medication observation, which involved 2 of 5 residents (Resident #81, Resident #78 and Resident #34) and 1 of 7 staff (RN F) observed during medication administration reviewed for medication errors. 1. RN F failed to administer Lacosamide Oral Tablet 150 MG (Lacosamide) (to treat partial-onset seizures), to Resident #81 on 3/24/26.2. RN F failed to administer MiraLAX Oral Powder 17 GM(grams)/SCOOP(Used to treat occasional constipation) to Resident #81 on 3/24/26.3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents are were free of any significant medication errors for 2 of 18 residents (Resident #68 and Resident #81) reviewed for medications. The facility failed to ensure that Resident #68's blood pressure medications hydralazine and telmisartan were held within the parameter the physician ordered. 2. RN F failed to administer Lacosamide Oral Tablet 150 MG (Lacosamide) (to treat partial-onset seizures), give 1 tablet via PEG-Tube every 12 hours for nausea, initialed as given to Resident #81, when it was not given on 3/24/26. These failures could place residents with high or low blood pressure at risk of fainting or a stroke due to not getting their blood pressure medication as ordered by their physician. 1. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.1. The facility failed to ensure leftover food consisting of sliced American cheese and shredded cheese past their use by dates were discarded. 2. The facility failed to ensure scrambled eggs, pureed sausage, pureed beef, brown gravy left outside on pans which were to be used later with temperatures in the danger zone were discarded. 3. The facility failed to ensure frozen pork chops were thawed properly.4. The facility failed to ensure equipment/serving utensils were washed and sanitized. These failures could place residents who ate food from the kitchen at risk of foodborne illness and disease. [...]

Inspectors wroteBased on observation, interview, and record review, 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 3 of 10 residents (Residents #34, Resident #66 and Resident #81) and 1 of 3 staff (RN F). The facility failed to ensure that personal wash basins, emesis basins and toothbrushes were labeled with resident's names to prevent infection. RN F failed to sanitize the blood pressure cuff between Resident #81 and Resident #34 on 3/24/26. RN F failed to wear PPE when administering Resident #81's G-Tube medications, who was on EBP, on 3/24/26. Resident #66 was observed with his catheter bag on the floor on 03/24/2026. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 3 (Resident #66) reviewed for care plans .-The facility failed to ensure Resident #66's behavior of placing his catheter bag on the floor was documented in the care plan. This failure could place residents at risk of staff not being aware of how to provide care tailored to individual residents' needs . Record review of Resident #66's face sheet, last captured on 03/27/2026, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accident hazards. LVN W failed to properly dispose of lancets, used to prick Resident #1's finger to obtain blood for the glucose checks, and threw it in the regular trash can rather than the sharps container attached to the side her medication cart. This failure could place residents at risk of harming themselves or others with unsecured equipment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Nurses Cart P) reviewed for medication storage. -Nurse Cart P medication cart had medications that were opened and undated. This failure could place residents at risk of receiving expired medication and improperly stored medications which could result in delayed healing. Findings During an observation on [DATE] at 2:35pm of Nurse Cart P revealed the following opened medications were not dated when they were opened: The following eye drops and nasal drops were open with no date:1. Loteprednol Etabonate Ophthalmic2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters (dumpster A) reviewed for sanitary conditions. The facility failed to ensure dumpster A's lids and doors were secured. The failure could place residents at risk of infection from improperly disposed garbage . Observation on 3-24-26 at 8:45 AM revealed the facility dumpster area had 2 commercial sized dumpsters. Dumpster A was 3/4 full of garbage and the doors were open and the surrounding area had an accumulation of debris. In an interview with the food service manager on 3/24/26 at 8:45 AM she stated that the dumpster doors must always be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She further stated that housekeeping and nursing also discard their waste and garbage in the dumpster. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.-The facility failed to ensure residents' lunch was served at a safe temperature on 3/6/2026. These failures could place residents who ate food from the kitchen at risk of foodborne illness and disease. Observation of food temperature and interview on 3/6/2026 at 12:39pm, the DM delivered a regular lunch test tray which included fish tenders, hushpuppies, potato wedges and coleslaw. She left immediately to get a thermometer, alcohol wipes and a glass of ice water and came back at 12:45pm. The DM placed the thermometer in the ice water, and the temperature reading was 32.9F. [...]

Inspectors wroteBased on observation, interview, and record review 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 infection for 1 of 6 residents (Resident #5) and 2 of 2 staffs (CNA KK, CNA HH) reviewed for infection control. -The facility failed to ensure CNA FF donned PPE before transferring Resident #5 via mechanical lift from her bed to her wheelchair on 3/6/26. -The facility failed to ensure CNA HH donned PPE before transferring Resident #5 via mechanical lift from her bed to her wheelchair on 3/6/26. This failure could place residents at risk for spread of infection and cross contamination to residents causing resident illness and/or distress. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 (Resident #5) of 1 resident reviewed for PASARR.-The facility failed to submit a complete and accurate request for nursing facility specialized services for Resident #5 in the LTC Online Portal within 20 business days. This failure could place residents at risk of not receiving necessary services to help them achieve their highest possible mental and physical well-being. Record review of Resident #5's face sheet dated 03/06/2026, revealed she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #13) reviewed for accident hazards. The facility failed to ensure Resident #13's electrical bed remote did not have exposed wiring, with the inner blue, green and red wires separated from the white outer sheath. This failure could place residents at risk of injury from using damaged electrical equipment. Record review of Resident #13's face sheet dated 3/6/2026, revealed she was an [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE] . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #22) reviewed for incontinent care. -The facility failed to ensure CNA FF changed gloves and cleaned Resident #22's scrotum and buttocks before putting on a clean brief during incontinent care on 3/6/26. This failure could place residents at risk for pain, infection, injury, and hospitalization. Record review of Resident #22's face sheet dated 03/06/2026 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 (CR#1) of 10 residents reviewed for infection control. The facility failed to clean and disinfect blood from the wall and carpet in Room B, after CR#1 had a fall on 12/31/25 the resulted in a head injury. These failures could place residents at risk of sickness, infection, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment for residents, staff, and the public for 1 (CR #1) of 10 residents reviewed for sanitary conditions. CR#1 was transferred from room A to room B on 12/30/25. Room B had scuff marks along the walls and baseboards, scuff marks that exposed the dry wall along the walls, and clothing and a wheelchair that belonged to previous residents. These failures could place residents at risk of illness, contamination, and infection.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the resident review (PASARR) program under Medicaid in subpart C for 1 (Resident #1) of 2 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the initial IDT meeting held on 6/14/24. This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely in regards to clean bed and bath linens that are in good condition for 3 of 6 residents (Residents #1, Residents #30 and Residents #59) and 2 of 4 rooms (room [ROOM NUMBER]-B, 605-A, 605-B, 805-A, and 808) reviewed for environment. - The facility failed to address an unsecure wall socket in room [ROOM NUMBER]-B. - The facility failed to address discoloration on walls near resident (rooms 605-A, 605-B, and 805-A) headboards. - The facility failed to address discoloration on wall behind door in room [ROOM NUMBER]. - The facility failed to clean vacuum, and dust Resident #59's room. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, including screening for 1 of 25 staff reviewed for abuse. -The DON did not have an annual EMR (Employee Misconduct Registry) check conducted between 07/28/2023 and 01/09/2025. This can put residents at risk of abuse, neglect and exploitation by receiving care from staff members who were unemployable.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 2 medication storage rooms reviewed for pharmaceutical services. The facility failed to ensure there was not 5 expired heparin flushes (6 ml), dated 07/2024, in their medication room on the long-term care hall. This failure could place residents at risk for medication not being therapeutic, effective, or unwanted adverse reaction decreasing the quality of life.

Inspectors wroteBased on observation, interview and record review 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 3 of 8 residents (Residents #63, #68 and #195) reviewed for infection control . 1. The facility failed to place infection control signage on Resident # 195's door until 01/08/25, 2 days after the resident was admitted to the NF on 01/06/25 with an indwelling Foley catheter and lesions on her body. 2 The facility failed to place Resident #63's oxygen tubing inside of bag when not in use. 3. The facility failed to change Resident #63's oxygen tubing after the tubing was observed on floor on 01/07/25. 4. RN F failed to dispose of Resident #63's oxygen tubing to prevent infections on 01/08/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 9 Residents (Resident #296) who was observed for call light placement. The facility staff failed to ensure the call light was within reach for Resident #296. This deficient practice could affect any resident and keep them from calling for help as needed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 6 residents (Resident #68) reviewed for incontinent care. 1. CNA I failed to provide incontinent care for Resident #68 at least every 2 hours. 2. CNA I failed to thoroughly clean Resident #68 when providing incontinent care These failures could place residents at risk for urinary tract infections, hospitalization and decrease in quality of life.

Inspectors wroteBased on observation. interview and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #63) reviewed for oxygen. - The facility failed to place Resident #63's oxygen tubing inside of bag when not in use. - The facility failed to change Resident #63's oxygen tubing after the tubing was observed on floor on 01/07/25. - The RN F failed to dispose of Resident #63's oxygen tubing to prevent infections on 01/08/25. This failure could put residents at risk of not receiving consistent respiratory care and lead to a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 2 of 5 residents (Resident #1 and Resident #2) reviewed for privacy in that: -The facility failed to ensure CNA J provided privacy during incontinent care for Resident #1. -The facility failed to ensure CNA D provided privacy during incontinent care for Resident #2. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 3 of 5 residents (Resident #1, Resident #2, and Resident # 3) reviewed for ADLs. The facility failed to ensure Resident #1, Resident #2 and Resident #3 were provided with timely incontinent care by facility staff. This failure could place residents at risk for discomfort, skin breakdown, and urinary tract infections.

Inspectors wroteBased on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full-time basis for 1 of 4 staff reviewed. The facility's DON had an RN license which expired [DATE]. This deficiency placed residents at risk of not having a licensed DON regularly provide oversight, guidance, and direction for nursing staff.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 11 of 11 Staff (CNA W, CNA L, CNA M, Dietary aide H, Housekeeper E, CNA T, Wound care Nurse, CNA P, ADON, Administrator and Maintenance director) reviewed for infection control. - The facility failed to ensure CNA W followed proper hand hygiene and infection control procedures while passing hydration on hall 500. - The facility failed to ensure CNA L and CNA M did not wear gloves on the hallway. - The facility failed to ensure Dietary aide H and Housekeeper E did not wear gloves on the hallway. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 2 of 6 residents (Resident #55 and #10) reviewed for respiratory therapy in that: The facility failed to follow the physician orders for Resident #55' s oxygen administration and concentrator filter was covered with substantial amount of white substance. The facility failed to follow the physician orders for Resident #10's oxygen administration. These failures placed residents who received oxygen therapy at risk of respiratory complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were secured and stored properly for 1 of 4 nurses medication carts (memory care Medication Cart) medication storage. RN D failed to ensure the Memory Care Nurse medication cart was locked when it was left unattended on 11/16/23. This failure could place residents at risk for possible drug diversions or accidental ingestion.

Inspectors wroteBased on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure waste was properly contained in a dumpster when on 11/15/2023 the dumpster top lid and side door were not secured. This failure could place residents at risk of infection from improperly disposed garbage.