Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Falcon Lake Nursing Home, Llc during CMS and state inspections, most recent first.
A resident with ESRD on dialysis, diabetes with foot ulcers, heart failure, and depression, who was cognitively intact and independent in self-care, was issued a 30‑day discharge notice related to non‑payment and behavioral concerns. The notice, however, specified a discharge date only a few days after issuance rather than 30 days later. Social services documented active planning for the resident’s move to an apartment and coordination with community providers, but the resident was hospitalized before the 30‑day period elapsed. When the hospital prepared to discharge him back, facility leadership informed the Ombudsman that the owner did not want to take him back and did not want to honor the 30‑day notice, and the resident was not readmitted during the 30‑day window. Surveyors found this constituted a failure to provide a proper 30‑day discharge date and a failure to readmit the resident from the hospital within that 30‑day period, violating discharge requirements.
A resident with multiple chronic conditions and intact cognition received a 30‑day discharge notice that listed the reason for discharge and an effective date but omitted the discharge destination and the required contact information for the State LTC Ombudsman. The notice instead directed the resident to contact the ADM to initiate an appeal. The OMB confirmed the notice lacked Ombudsman information, and the resident reported receiving and disagreeing with the notice and pursuing an appeal. The ADM and DON acknowledged uncertainty about required notice contents, with the DON having obtained a template from an online search rather than following facility policy, which required inclusion of the discharge location and Ombudsman contact details.
A resident with multiple chronic conditions and intact cognition exhibited ongoing inappropriate and disruptive behaviors, including vulgar and sexually inappropriate comments to staff, taking staff and facility belongings, moving furniture from other rooms, playing loud music that disturbed others, and recording staff with a phone. Despite documented behavior-related incidents and staff reports, the resident’s comprehensive care plan did not include any problem statements, goals, or measurable interventions addressing these behaviors, and staff responses were limited to verbal redirection and informal education. This was inconsistent with the facility’s policy requiring ongoing assessment and revision of person-centered care plans with measurable objectives and timetables.
Surveyors found a medication cart on one hall and a wound care cart near the nurse station unlocked and unattended, with multiple bulk medications, blister packs, and supplies easily accessible. A resident in a wheelchair was seated about a foot from the unlocked medication cart. An LVN acknowledged he had forgotten to lock both carts when stepping away briefly and recognized the importance of securing them to prevent resident access and potential illness. The ADON and DON confirmed that all medication and wound care carts are required to be locked when not in use, and facility policy states that all compartments containing drugs and biologicals, including carts, must be locked and not left unattended if open.
A resident with dementia and a history of repeated falls experienced two unwitnessed falls that were documented in the care plan and incident log but were not recorded on the discharge MDS assessment. The ADON and DON both indicated a lack of understanding and oversight regarding the proper coding of falls, resulting in inaccurate MDS documentation.
A resident with Alzheimer's and high elopement risk had incomplete and inaccurate documentation regarding her wander guard monitoring. Staff failed to ensure the guard was worn as per policy, with records showing unsigned sections and incorrect entries. The DON acknowledged gaps in training and policy implementation, impacting resident safety.
The facility failed to maintain food safety and sanitation standards, with issues including ice build-up in the kitchen freezer, dirty coffee cups, and unlabeled, undated, and expired food items in the nutrition room refrigerator. Staff interviews revealed a lack of awareness and responsibility for these issues, and facility policies on food storage and maintenance were not followed.
A resident with a PEG tube did not receive proper infection control care from an LVN, who failed to follow Enhanced Barrier Precautions and hand hygiene protocols. The LVN did not wash or sanitize hands or change gloves appropriately during the procedure, despite handling various items and recognizing redness at the PEG site. Interviews revealed a misunderstanding of infection control measures, despite regular training.
The facility failed to maintain a safe and sanitary environment in the laundry area, with issues such as difficult-to-open doors, suspected mold on walls, and a leaking washing machine attracting mosquitoes. Staff reported these problems to the maintenance supervisor, but they remained unaddressed. The administrator was unaware of the issues due to reliance on the maintenance supervisor's assurances and ineffective monitoring of the maintenance log.
Improper Discharge Notice and Failure to Readmit a Resident Within 30-Day Period
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was permitted to remain in the facility and not be transferred or discharged in violation of federal discharge requirements. The resident was an adult male with multiple serious chronic conditions, including type 2 diabetes with neuropathy and foot ulcers, end-stage renal disease on dialysis, heart failure, hypertension, major depressive disorder, and atherosclerotic heart disease. He had a BIMS score of 13, indicating no cognitive impairment, and was independent in self-care, using a walker and electric wheelchair. Active discharge planning toward community placement had been documented, and the resident had previously approached social services requesting assistance with a possible future discharge to live alone with services. The record shows that the resident was first issued a 30‑day discharge notice on one date in late January, which he appealed and won due to a technicality. Despite this, he remained behind on his Medicaid applied income payments for several months, accumulating a significant balance. On a later date in early March, the DON and administrator again issued a 30‑day discharge notice, citing continued non‑payment and ongoing behavioral concerns. However, the notice given on that date listed an effective discharge date only a few days later, rather than 30 days from the notice date. The resident and the Ombudsman both reported that the second notice was dated with a discharge date six days after issuance, and the Ombudsman stated the facility documented that he was to be discharged to an apartment. Social service notes on the same day as the second notice document extensive discussions with the resident about his planned move to an apartment, his lack of payment of applied income, and his conflicting statements about wanting to leave versus wanting to stay. The SW documented contacts with an apartment complex, home health agency, dialysis center, and other community resources, and noted that the apartment would be available around the 11th or 12th of that month. The resident was then sent to the hospital shortly after this planning. Before the 30th day from the second 30‑day notice had elapsed, the resident was ready for discharge from the hospital and expressed a desire to return to the original facility while he awaited finalization of his apartment. The Ombudsman reported that the administrator stated the owner did not want to take the resident back and did not want to honor the 30‑day notice. The facility did not readmit the resident when he was discharged from the hospital prior to the 30th day after the 30‑day notice, resulting in a failure to provide a proper 30‑day discharge date and a failure to readmit him during that 30‑day period as required. Throughout his stay, the record reflects multiple behavioral incidents, including verbal agitation, sexually inappropriate comments toward staff, attempts to enter restricted areas such as the medication room, going into other residents’ rooms, recording staff and residents on his phone, and frequent threats to report staff to the state. Staff, including CNAs, LVNs, the ADON, DON, and facility owners, reported feeling uncomfortable or unsafe due to his comments, recording behavior, and perceived threats. The facility owners and leadership cited these behaviors, along with his refusal to pay applied income, as reasons for pursuing discharge. However, despite these concerns and the ongoing discharge planning, the facility did not provide a discharge date that was 30 days after the 30‑day notice and did not allow the resident to return from the hospital before the 30‑day period expired, which surveyors identified as a failure to ensure the resident’s right to remain in the facility and to be transferred or discharged only in accordance with regulatory requirements.
Noncompliant Discharge Notice Lacking Required Destination and Ombudsman Information
Penalty
Summary
The facility failed to issue a compliant 30‑day discharge notice to a cognitively intact male resident with multiple diagnoses including type 2 diabetes, major depressive disorder, heart disease, end‑stage renal disease, and dependence on renal dialysis. Record review showed the undated 30‑day discharge notice listed the reason for discharge as the facility’s inability to provide appropriate care for his specific needs and included an effective discharge date and a brief statement about appeal rights directing the resident to contact the ADM. However, the notice did not specify the location to which the resident would be discharged and did not include the name, mailing and email address, or telephone number of the State Long‑Term Care Ombudsman. The facility’s own Transfer and Discharge Notice policy required that the written notice include the location of transfer or discharge and the Ombudsman’s contact information. Interviews confirmed these omissions and the staff’s lack of understanding of the required notice content. The Ombudsman reported receiving the 30‑day discharge notice by email and stated that the notice given to the resident did not contain Ombudsman information, even though regulations require it so residents can appeal. The resident reported receiving the 30‑day notice from the ADM and DON, understood the stated reason for discharge, disagreed with it, and had contacted the Ombudsman to appeal; he was not injured or in distress. The ADM acknowledged he did not know the notice should indicate the discharge location, was unsure whether the Ombudsman’s information was included, and stated he followed a template provided by the DON. The DON stated she was unsure what information the notice was supposed to contain and had obtained a template via a web search, rather than from facility policy, leading to a notice that did not meet the facility’s policy requirements.
Failure to Care Plan Resident’s Inappropriate and Disruptive Behaviors
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s inappropriate behaviors. The resident was an adult male with type 2 diabetes, major depressive disorder, heart disease, end stage renal disease, and dependence on renal dialysis, with an MDS BIMS score of 13 indicating intact cognition. The resident’s care plan, dated 01/30/26, did not include any problem, goals, or interventions related to inappropriate behaviors such as making rude or vulgar comments, taking facility or staff items, playing music loudly, or recording staff with his phone. Progress notes between 08/29/25 and 01/30/26 documented at least two behavior-related incidents: one where the resident used vulgar language and made sexually inappropriate comments to staff, and another where he removed furniture from other rooms and placed it in his own room, for which staff only provided education about safety. In interviews, the ADON and DON both confirmed that the resident had ongoing inappropriate behaviors, including making rude or sarcastic comments about staff bodies, taking staff meals and facility items (such as a nurse station chair) to his room, playing music loudly enough that other residents complained they could not sleep, and recording staff with his phone. The ADON stated staff verbally redirected the resident and asked him to use headphones at night, but she was unsure if these behaviors were care planned. The DON acknowledged that the behaviors were not included in the care plan, that staff only verbally redirected the resident, and that no other interventions were implemented. The facility’s own policy required a comprehensive, person-centered care plan with measurable objectives and timetables, and specified that assessments are ongoing and care plans are revised as resident information and conditions change, but this was not done for this resident’s behavioral issues.
Unlocked Medication and Wound Care Carts Left Unattended
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all drugs and biologicals were stored in locked compartments when not in use, as required by facility policy and professional standards. During an observation, a medication cart assigned to an LVN on the 400 hall and a wound care cart located by the nurse station were found unlocked and unattended. The surveyor was able to open the top drawers of both carts, confirming they were not secured. Multiple medications in bulk bottles, supplies, and blister packs were easily accessible for removal. A resident in a wheelchair was observed sitting approximately one foot away from the unlocked medication cart. In an interview, the LVN responsible for the 400 hall medication cart and the wound care cart stated he had forgotten to lock the carts when he stepped away briefly to get something. He acknowledged the importance of locking the carts to prevent residents from accessing medications and stated that if a resident obtained medications, they could take something they were not supposed to and become sick. The ADON and DON both stated that all medication and wound care carts should be locked when not in use, and that leaving them unlocked and unattended could allow unauthorized individuals to access the contents, potentially resulting in drug diversion or accidental ingestion. Review of the facility’s Storage of Medications policy confirmed that all compartments containing drugs and biologicals, including carts, must be locked when not in use and that carts used to transport such items must not be left unattended if open or otherwise available to others.
Failure to Accurately Code Resident Falls on MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status by not documenting two unwitnessed falls that occurred on 6/1/25 and 6/18/25. The resident, who had diagnoses including dementia, muscle wasting, repeated falls, muscle weakness, and gait abnormalities, was identified as high risk for falls. The comprehensive care plan and the facility's incident log both documented the falls, but the discharge MDS indicated that no falls had occurred since admission or the prior assessment. Interviews with the ADON and DON revealed that the falls were not captured on the discharge MDS due to oversight and a lack of understanding regarding the coding requirements for falls. The ADON acknowledged missing the falls section on the MDS and was unsure of the importance of capturing this information. The DON was also unclear about the look-back period for falls in the MDS and confirmed that the omission resulted in incorrect documentation. The CMS RAI Manual specifies that any falls since admission or the prior assessment should be coded, but this was not followed in this case.
Inaccurate Documentation of Wander Guard Monitoring
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident, specifically regarding the monitoring of a wander guard. The resident, who had Alzheimer's disease and was at high risk for elopement, had a physician's order for a wander guard to be checked every shift. However, the monitoring administration records for February 2025 showed incomplete and inaccurate documentation, with unsigned sections and incorrect entries by staff. On multiple occasions, the resident's wander guard was found not on her person but in her walker bag, contrary to the facility's policy that it should be worn at all times. RN A inaccurately documented that the wander guard was in place when it was not, and other staff members, LVN B and LVN C, failed to document the wander guard checks during their shifts. Interviews with the staff revealed a lack of adherence to documentation protocols and an absence of a specific policy for wander guard placement. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were responsible for ensuring accurate documentation, but there was no clear policy or consistent training regarding wander guard monitoring. The DON acknowledged the importance of accurate documentation for resident safety and compliance with physician orders but admitted to gaps in staff training and policy implementation. This deficiency in documentation could potentially impact the care and safety of residents at risk for elopement.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in the storage, preparation, distribution, and serving of food. Observations revealed significant ice build-up in the kitchen freezer, which could potentially impede airflow and cause equipment failure. Interviews with staff indicated that the ice build-up had been a persistent issue since the previous year, and despite attempts to remove the ice, it continued to accumulate. The maintenance staff had not contacted a service company to address the problem, and the last service was conducted a year ago, which did not resolve the issue. Additionally, the facility did not provide clean coffee cups for residents, as all cups observed were heavily stained and scratched. The nutrition room refrigerator contained multiple unlabeled and undated food items, including cookies, fruit, jam, juice, bacon, cream cheese, and an energy drink. Some items were also expired, and there was no thermometer in the unit freezer to monitor temperatures. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed they were unaware of these issues and did not know who was responsible for monitoring the nutrition room refrigerators. The facility's policies on food storage and maintenance were not followed, as evidenced by the lack of labeling, dating, and proper storage of food items. The maintenance log was not available, and the Administrator was unaware of the freezer's condition and the lack of monitoring in the nutrition refrigerator. The facility's failure to maintain sanitary conditions and proper food storage practices could place residents at risk of foodborne illness and living in an unsafe environment.
Inadequate Infection Control During PEG Tube Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during PEG tube care for a resident. The resident, who was non-verbal, blind, and spoke only Spanish, had a PEG tube and was incontinent. During the care procedure, LVN A did not adhere to Enhanced Barrier Precautions (EBP) as recommended by the CDC for residents with indwelling medical devices. LVN A did not wash or sanitize her hands before or after the procedure, nor did she change gloves appropriately, which are critical steps in preventing cross-contamination and infection. During the observation, LVN A was seen handling various items and performing tasks without changing gloves or sanitizing her hands. She touched the feeding pump, bed control, and other supplies without following proper hand hygiene protocols. Despite recognizing the slight redness at the PEG site, LVN A continued to use the same gloves throughout the procedure, including when handling sterile gauze and securing the dressing with tape. This lack of adherence to infection control practices was acknowledged by LVN A, who admitted to not following the handwashing protocol and misunderstanding the requirements of EBP. Interviews with LVN A and the facility's administrator revealed gaps in understanding and implementation of infection control measures. LVN A admitted to confusion about EBP and acknowledged her failure to wash or sanitize her hands, which she recognized could lead to cross-contamination. The administrator expressed concern over the staff's non-compliance with infection control guidelines, despite regular training. The facility's hand hygiene policy, which emphasizes hand hygiene as the primary means to prevent infection spread, was not followed, contributing to the deficiency in infection control practices.
Laundry Room Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the laundry area, as observed during a survey. The entrance door to the laundry room was difficult to open and close, with deep grooves in the floor where the door dragged, and a hole in the wall where the door handle would hit. Another door lacked an inner handle, and a room inside the laundry had dark patches on the walls, suspected to be mold. Additionally, a washing machine was leaking water into a basin, attracting mosquitoes, and a stray cat was observed entering the laundry room due to the door not shutting completely. Interviews revealed that the housekeeping staff had been experiencing these issues for years and had reported them to the maintenance supervisor (MS) multiple times. The MS acknowledged being aware of the issues but had not addressed them due to other renovation work. The administrator (ADM) was unaware of the problems, as she relied on the MS's assurance that everything was fine. The facility's maintenance policy required maintaining the building in a safe and operable manner, but the handwritten maintenance log used for repair requests was not effectively monitored, and the ADM was unable to locate it.
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