COLORADO SPRINGS, CO - Falcon Heights Rehabilitation and Nursing LLC encountered significant regulatory violations during a July 2024 state inspection, with investigators documenting serious issues in medical care continuity, medication administration, and basic safety protocols that potentially affected dozens of residents.
Medical Group Transition Creates Care Gaps
The facility's most concerning violation involved failing to inform residents or their families about a corporate decision to change primary medical groups. According to the inspection report, this transition created dangerous gaps in medical coverage that lasted over a month.
The Director of Nursing reported that after the corporation switched medical providers, "it took over a month for the new medical group to enter the facility and see residents." More troubling, the new physicians frequently failed to return urgent calls from nursing staff during nights and weekends. When nurses couldn't reach the new doctors within 15 minutes, they were directed to contact the retired medical director for guidance, even though he was no longer officially responsible for patient care.
This breakdown in medical communication led to at least one emergency room visit that could have been prevented. When nursing staff couldn't reach on-call physicians for Resident #9 who experienced a change in condition on June 4, 2024, the retired medical director - uncomfortable treating a patient who wasn't technically his - ordered her sent to the emergency room. Professional standards require physician evaluation within 24 to 48 hours after hospitalization, but this resident reportedly wasn't seen by facility physicians for more than 10 days.
Such delays in medical care can have serious consequences for nursing home residents, who often have complex health conditions requiring prompt attention. When physicians are unavailable or unresponsive, conditions can deteriorate rapidly, leading to unnecessary hospitalizations, complications, or worse outcomes.
Medication Administration Failures Put Residents at Risk
Inspectors identified multiple medication-related violations that directly impacted resident care and safety. In one documented case, a licensed practical nurse failed to administer prescribed pain medication to a 76-year-old resident with chronic arthritis, then falsely recorded on the medication administration record that the medication had been given.
Resident #43, who experienced "almost constant pain" from arthritis affecting her wrists, neck, lower back, hips, and arms, was prescribed Biofreeze gel four times daily. During the inspection, she told investigators she hadn't received her pain cream for two consecutive days, stating "the arthritis cream really helped with her pain but since she had not received it she felt achy all over."
When confronted, the nurse admitted she "could not remember if she had administered the medication that day" but acknowledged she "should not have marked off the medication as given on the MAR when she did not administer the medication." The Director of Nursing expressed concern about "what other medications LPN #5 might not have administered but had signed off as she had."
This type of medication error is particularly dangerous because it creates false documentation that can mislead other healthcare providers and prevent residents from receiving needed care. Pain management is crucial for nursing home residents' quality of life and overall health outcomes.
Widespread Medication Safety Problems
Beyond individual administration errors, the facility demonstrated systemic problems with medication management. Inspectors found an 8% medication error rate during observations - exceeding the 5% maximum allowed by regulations. Multiple violations included:
Improper Self-Administration Protocols: Three residents were found with medications at their bedsides without proper physician orders or safety assessments. Residents had eye drops, nasal sprays, pain relief sprays, and other medications accessible to themselves and potentially other residents, including those with cognitive impairments who might accidentally consume them.
Expired and Improperly Stored Medications: Throughout the facility, staff maintained expired medications on carts and in storage areas. Found items included Tylenol that expired in June 2024, vitamin supplements expired since April 2024, and critical medications like lorazepam expired since April. One insulin pen lacked required opening date labels, making it impossible to determine safety for use.
Dosage and Timing Errors: Nurses administered incorrect dosages and gave medications at inappropriate times. One resident received only half their prescribed antidepressant dose, while another received thyroid medication 89 minutes late and after eating breakfast, when the medication requires an empty stomach for proper absorption.
These medication management failures create multiple risks. Expired medications may be ineffective or harmful, while incorrect dosages can lead to treatment failures or adverse reactions. Poor timing can reduce medication effectiveness or cause dangerous interactions.
Safety Hazards and Inadequate Supervision
The inspection revealed concerning safety issues affecting multiple residents. One cognitively intact resident with tremors caused by neurological conditions burned her fingers while smoking, yet the facility failed to conduct a thorough investigation into how this incident occurred.
Despite facility policies requiring "direct supervision throughout the entire smoking period" for unsafe smokers, this resident was able to obtain cigarettes from unauthorized sources and smoke without proper oversight. The burns measured up to 3 centimeters, indicating a significant injury that could have been prevented with proper supervision.
The facility also struggled with residents who had severe cognitive impairment and wandering behaviors entering other residents' rooms uninvited, creating safety and privacy concerns.
Food Service and Sanitation Deficiencies
Multiple residents complained about food quality, temperature, and timing issues. Residents reported meals were "always served late," tasted "terrible," and were frequently delivered cold. One dialysis patient said kitchen staff often forgot to prepare his dinner for medical appointments, offering only inadequate peanut butter sandwiches that left him feeling sick from hunger.
Test trays evaluated by inspectors confirmed these complaints, revealing overcooked, dry pork, bland and watery gravy, and mushy vegetables. The dietary manager acknowledged the food quality issues, admitting the pork was overcooked and gravy was watery due to rushed preparation.
Sanitation problems in the kitchen included improper testing of chemical sanitizing solutions. Staff were testing sanitizer concentration only once daily instead of the manufacturer's recommended three times daily, with some readings showing dangerously low sanitizer levels that could allow bacterial contamination.
Infection Control Lapses
Nursing and housekeeping staff failed to follow basic infection prevention protocols. Nurses were observed administering medications to multiple residents without performing hand hygiene between patients. Housekeeping staff cleaned bathrooms and resident rooms without changing gloves or washing hands, potentially spreading infections between areas.
These failures are particularly concerning in nursing home settings, where residents often have compromised immune systems and are at higher risk for healthcare-associated infections.
Additional Issues Identified
The facility also faced violations for non-functional exhaust fans in shower rooms, creating humid conditions with strong odors that affected the living environment. The maintenance supervisor admitted ventilation systems weren't included in regular maintenance tracking, allowing problems to go unaddressed.
The inspection revealed systemic issues across multiple departments, suggesting broader problems with oversight, training, and quality assurance programs. The facility's management acknowledged the violations and committed to immediate staff education and monitoring improvements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Falcon Heights Rehabilitation and Nursing LLC from 2024-07-31 including all violations, facility responses, and corrective action plans.
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