Deficiency Records for Falcon Lake Nursing Home, LLC
Updated as of June 01, 2022
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? |
|---|---|---|---|---|
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-02-04 | 2022-03-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-04 | 2022-03-25 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-01 | 2022-02-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-01 | 2022-02-02 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-03-05 | 2021-04-16 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-03-05 | 2021-04-16 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-03-05 | 2021-04-16 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-04 | 2021-04-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-03-04 | 2021-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-04 | 2021-04-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-03-04 | 2021-04-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-04 | 2021-04-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-04 | 2021-04-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-01-14 | 2021-02-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-01-14 | 2021-02-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-29 | 2020-11-21 | Y |
| 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-07 | 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 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-07 | 2019-10-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-07 | 2019-10-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-09-07 | 2019-10-15 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-09-07 | 2019-10-15 | Y |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-05-31 | 2019-07-20 | 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 smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-31 | 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 |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-04 | Not Fixed | N |
