Deficiency Records for Falcon Lake Nursing Home, LLC
Updated as of July 01, 2020
This is not the most recent data for Falcon Lake Nursing Home, LLC. For the most recent information, click here.
A list of the most recent deficiencies for Falcon Lake Nursing Home, 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-16 | 2019-12-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-10-16 | 2019-11-28 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-10-16 | 2019-11-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-16 | 2019-11-08 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-10-16 | 2019-11-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-16 | 2019-11-05 | Y |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-05-31 | 2019-07-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-31 | 2019-07-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-05-30 | 2019-07-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-30 | 2019-07-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-05-30 | 2019-07-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-05-30 | 2019-07-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-30 | 2019-07-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-05-30 | 2019-07-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-30 | 2019-07-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-30 | 2019-07-13 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-05-30 | 2019-07-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-30 | 2019-07-13 | 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 | 2019-05-30 | 2019-07-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-30 | 2019-07-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-05-30 | 2019-07-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-31 | 2019-06-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-10-03 | 2018-11-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-03 | 2018-11-03 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-04-25 | 2018-06-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-04-25 | 2018-06-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-25 | 2018-06-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-04-23 | 2018-06-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-25 | 2018-05-30 | N |
| Be properly staffed | Fire Safety | 2018-04-23 | 2018-05-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-23 | 2018-05-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-04-06 | 2017-05-15 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2017-04-06 | 2017-05-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-04-06 | 2017-05-15 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2017-04-06 | 2017-05-15 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2017-04-06 | 2017-05-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-04-06 | 2017-05-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-04-06 | 2017-05-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-04-06 | 2017-05-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-04-06 | 2017-05-15 | N |
| Tell the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2017-04-06 | 2017-05-15 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2017-04-06 | 2017-05-15 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-04-06 | 2017-05-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-04-06 | 2017-05-15 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-04-06 | 2017-05-15 | N |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2017-04-06 | 2017-05-15 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-04-06 | 2017-05-15 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-04-06 | 2017-05-15 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-06 | 2017-05-15 | N |
| 1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compensation. | Health | 2017-04-06 | 2017-05-15 | N |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2017-04-06 | 2017-05-15 | N |
| Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. | Health | 2017-04-06 | 2017-05-15 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-06 | 2017-05-15 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-06 | 2017-05-15 | Y |
