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Deficiency Records for Falcon Heights Rehabilitation and Nursing LLC
A list of the most recent deficiencies for Falcon Heights Rehabilitation and Nursing LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Falcon Heights Rehabilitation and Nursing LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-24 | 2024-10-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-09-24 | 2024-10-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-31 | 2024-08-28 | N |
| 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. | Health | 2024-07-31 | 2024-08-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-31 | 2024-08-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-31 | 2024-08-28 | N |
| Provide activities to meet all resident's needs. | Health | 2024-07-31 | 2024-08-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-31 | 2024-08-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-07-31 | 2024-08-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-07-31 | 2024-08-28 | N |
| 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. | Health | 2024-07-31 | 2024-08-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-07-31 | 2024-08-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-31 | 2024-08-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-31 | 2024-08-28 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2024-07-31 | 2024-08-28 | N |
| Honor the resident's right to choose his or her attending physician. | Health | 2024-07-31 | 2024-08-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-31 | 2024-08-28 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-21 | 2023-09-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-21 | 2023-09-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-21 | 2023-04-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-21 | 2023-04-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-21 | 2023-04-06 | N |
| 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. | Fire Safety | 2023-03-21 | 2023-04-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-21 | 2023-04-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-21 | 2023-04-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-21 | 2023-04-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-21 | 2023-03-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-22 | 2023-03-18 | N |
| Respond appropriately to all alleged violations. | Health | 2023-02-22 | 2023-03-18 | Y |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-12-07 | 2022-06-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-07 | 2022-04-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-12-07 | 2022-01-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-07 | 2021-12-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-07 | 2021-12-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-07 | 2021-12-26 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-11-18 | 2021-12-18 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-11-18 | 2021-12-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-11-18 | 2021-12-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-11-18 | 2021-12-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-18 | 2021-12-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-18 | 2021-12-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-18 | 2021-12-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-18 | 2021-12-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-18 | 2021-12-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-18 | 2021-12-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-18 | 2021-12-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-11-18 | 2021-12-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-18 | 2021-12-18 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-18 | 2021-12-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-18 | 2021-12-18 | Y |
| 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. | Fire Safety | 2024-08-27 | Not Fixed | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-08-27 | Not Fixed | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-27 | Not Fixed | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-27 | Not Fixed | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-27 | Not Fixed | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-08-27 | Not Fixed | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-08-27 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-08-27 | Not Fixed | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-08-27 | Not Fixed | N |
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