Falcon Ridge Rehabilitation

Inspectors wroteBased on record review and interview, the facility failed to use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility reviewed for RN coverage. The facility did not have RN coverage on [DATE], [DATE], [DATE], [DATE], and [DATE]. This failure could have placed residents at risk of not receiving adequate care or monitoring of staff that required the supervision or decision making of an RN. Record review of the facility's resident roster, dated [DATE], revealed a census of 90 residents. Record review of the facility's nursing time sheets from [DATE] through [DATE] reflected five dates with no RN coverage: [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 9:26 a.m., the DON stated the facility did not have RN coverage on the five identified dates. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the residents received services with reasonable accommodation for each resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 7 of 12 residents (Residents #3, #63, #76, #18, #04, #12, and #54) reviewed for call light accessibility. The facility failed to ensure the call light system was accessible to Residents #3, #63, #76, #18, #04, #12, and #54. This failure could place residents at risk of not being able to call for staff assistance to meet care needs or at risk of injury or pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post its most recent survey in an area accessible to residents, family members, and legal representatives of residents, in 1 of 1 survey binders. The facility failed to ensure the most recent standard survey was readily available for residents and families to review. This failure could leave residents without access to up-to-date information about the facility's compliance with federal and state regulations, limiting their ability to make informed decisions and exercise their rights. During a confidential group interview at an undisclosed date and time, 6 residents confirmed they did not have access to the most recent standard survey results and wanted to review them. An observation on 06/30/2026 at 4:05 PM indicated that the survey results were not posted where residents could have access to the binder . [...]

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 received necessary services to maintain personal hygiene for 1 of 20 residents reviewed for ADLs. (Resident # 99). The facility did not provide Resident #99, who required extensive assistance with bathing, with a shower/bath on scheduled days of 6/17, 6/19, 6/22, 6/24, 6/26 and 6/29/26. This failure could affect residents who received activities of daily living help from facility staff by placing them at risk for loss of dignity and self-worth, skin breakdown and discomfort. Record review of Resident #99's face sheet dated 07/01/26 revealed resident was a [AGE] year-old female with an initial admission date 06/17/26. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 2 kitchens reviewed for Food and Nutrition Services. The facility failed to ensure dietary staff followed proper handwashing and glove use. These deficient practices could place residents at risk for food borne illness. During an observation on 06/29/2026 at 10:40 a.m., in Kitchen 1, [NAME] E finished a task of pureeing meatloaf. She removed her gloves and she picked up a white dish rag from the preparation counter, and she moved it to the dirty linens pile. [NAME] E failed to wash hands before putting on a new pair of gloves and beginning to puree carrots for the lunch meal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three resident reviewed for accidents. CNA A failed to get assistance while providing care for Resident #1 who was a 2 -person assist. CNA A and the MDS Nurse failed to lock Resident #1's bed and Geri chair (a specialized, highly padded recliner on wheels) while transferring Resident #1 via mechanical lift from the bed to the Geri chair. This failure could place residents at risk for falls, injury and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices during a mechanical lift transfer for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was transferred per mechanical lift by two people. CNA A transferred Resident #1 from his bed to his motorized wheelchair without the assistance of another person. This failure could place the residents at risk of not receiving the care and services to meet their needs and puts them at risk for injury.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care. The facility failed to give Resident #1 his Biofreeze Gel 4% scheduled medication during the standard time frame for 13 days and did not get his Biofreeze Gel at all on 06/19/2025. These failures placed residents at risk of pain, and a decreased quality of life.

Inspectors wroteBased on 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, which include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of six residents (Resident #36) reviewed for comprehensive care plans. The facility failed to ensure Resident #36's care plan addressed that the resident received hospice service. This deficient practice could result in a loss of quality of life due to residents receiving improper care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food in the dry storage area was kept off the floor. This failure could affect residents by placing them at risk for accumulation of insects and/or rodents causing food-borne illness.

Inspectors wroteBased on observation, interview, and record review, it was revealed that 1 of 2 trash dumpsters, reviewed for proper trash containment, was not maintained in a sanitary condition to prevent the harborage of feeding pest. The facility failed to ensure an outside trash dumpster was properly sealed with the lid closed. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to reside and receive services in the facility with reasonable accommodation of needs and preferences for 1 of 8 residents (Resident #1) reviewed for accommodation of needs. The facility failed to ensure Resident #1 could access his call button on 12/18/24. This failure placed residents at risk of not being able to call for help if they need it.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 8 residents reviewed for prevention of pressure ulcer. The facility failed to ensure Resident #2 received weekly skin assessments in accordance with his care plan. This failure placed residents at risk of pressure ulcers going untreated.

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 received necessary services to maintain good nutrition, grooming, personal and oral hygiene for two (Resident #7 and Resident #8) of three residents reviewed for ADLs. The facility failed to provide showers to Residents #7 and #8 in compliance with their shower schedules. This deficient practice could place residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth.

Inspectors wroteBased on observations, interviews, and record reviews, 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, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 1 activity programs and two (Resident #1 and Resident #2) of four residents reviewed for activities. 1. The facility failed to provide an activity program designed to meet the interests and needs of Residents #1 and #2. 2. The facility failed to notify all residents of canceled and postponed activity programs. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop a base line care plan that included the instructions needed to provide effective and person-centered care of the resident, for one Resident (Resident #2) of four residents reviewed for base line care plans. The facility failed to timely and accurately assess resident's care plan needs. 1. Resident #2's baseline care plan problem start dates and approach dates for Residents #2's were dated 22 days and 21 days, respectively, prior to her admission to the facility. 2. Resident #2's care plan failed to address her preferred language, incontinent care, delirium, cognitive loss/dementia, activity preferences, and communication needs. 3. The care plan failed to address that Resident #2's functional abilities and goals reflected the use of the mobility device walker, and not a wheelchair. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. 1. The facility failed to ensure Resident #1's care plan, which called for floor mats to be on the floor at her bedside, was followed. No fall mat was observed beside Resident #1's bed. 2. The facility failed to prevent Resident #1 from sustaining a fall in her room and fracturing her left wrist. This deficient practice could affect residents by contributing to falls with injury, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen reviewed for sanitation. The facility failed to discard of food products that were past the use by date or in accordance with facility policy in the double door refrigerator, walk-in refrigerator, walk-in freezer, and dry storage area. The facility failed to label and date food products in the walk-in freezer and walk-in refrigerator. The facility failed to close food product bags in the walk-in freezer to prevent exposure to air. The facility failed to prevent mold growth on bottled products in the walk-in refrigerator. The facility failed to clean the industrial can opener. The facility failed to remove dented cans from the dry storage area to prevent service to residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 (Resident #19, Resident #32, Resident #76) of 19 residents reviewed for ADL care. The facility failed to provide fingernail care for Resident #19, Resident #32, and Resident #76. This failure could lead to a reduction in quality of life and could contribute to health-related issues from lack of hygiene.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1 (Hall 100-300) of 2 medication storage rooms and 1 (Rehabilitation Nurse's cart) of 3 medication carts reviewed for drug storage. The medication storage room for Halls 100-300 had one expired medication, one expired oral supplement and one expired topical paste used for ostomy (opening from inside the body to outside) care. The Rehabilitation Nurse's cart had one expired oral medication dated 2017. This failure placed residents at risk of receiving expired oral medications and supplements which could lead to reduced potency and adverse medication effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of their quality of life for two (Resident #3, Resident #18) of six residents reviewed for rights. The facility failed to provide sufficient staffing in the dining area to ensure residents were assisted with their meals in a dignified one-to-one manner. CNA I sat between Resident #3 and Resident #18, who required assistance with their meals, and assisted both at the same time. These failures placed the residents at risk of a decline of their sense of dignity, level of satisfaction with life, and feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #58) of 4 residents reviewed for enteral feeding. The facility failed to ensure that the head of Resident #58's bed was at an angle of at least 30 degrees and not more than 45 degrees while actively receiving enteral gastric tube feeding. This failure could affect residents in the facility receiving enteral feeding by placing them at risk of complications such as aspiration pneumonia. Findings Included: Review of Resident #58's Face Sheet dated 01/24/2024, reflected a 59 year of age male, who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff did not use physical, psychological, or verbal abuse on a resident for 1 of 5 residents (Resident #1) reviewed for abuse. Resident #1 stated CNA A had jerked him up out of bed at 2:00 AM to clean his room and CNA A told Resident #1 she didn't know why they were looking at his right leg because it needed to be cut off anyway. This failure could place residents at risk of fear and physical/psychosocial injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #2) out of three residents reviewed for abuse, in that: The facility failed to prevent a physical altercation between Resident #1 and Resident #2 that led to Resident #2 sustaining an abrasion to his left ear, redness to the back of the left side of his head and neck, causing him to have a headache and experience dizziness. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/31/23 at 3:00 PM. While the IJ was removed on 11/01/23 at 2:30 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for ADL care, in that: The facility failed to provide showers to Resident #1, Resident #2, and Resident #3 in compliance with their shower schedules. This deficient practice could place residents at risk of a decline in their sense of well-being, level of satisfaction with life, and at risk for skin breakdown.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare and ensure professional food service safety in the kitchen for all residents reviewed for sanitation, in that: Kitchen equipment was not clean/sanitary and there was standing water on the kitchen floor. This failure placed residents at risk for foodborne illness.