Resident #2 had a documented history of physical aggression when agitated by other residents. His care plans, revised as recently as November, warned that he would tell other residents to get out of his way and that he didn't want them there. He verbalized being unhappy at the facility and wandered into other residents' rooms.
The facility placed him on 15-minute safety checks specifically for his elopement risk and behavioral issues. Staff were supposed to redirect him when agitated and offer food or drink as interventions.
But when federal inspectors interviewed the nursing aides actually providing his care, they found a troubling gap.
Certified nurse aide #2 told inspectors on November 4 that she wasn't aware of where to look for specific information about resident behavioral triggers. She said she got information about residents during shift changes by walking through the unit with departing staff, and asked the nurse if she had questions.
CNA #1, who worked on Resident #2's unit, said he usually worked another hall and wasn't aware of any specific triggers that would cause the resident to act aggressively. He understood the 15-minute checks were to monitor the resident's location because he wandered, but wasn't aware of the September 9 incident.
That September incident had been significant enough to prompt a room change. According to facility records, Resident #2 became agitated and aggressive toward another resident and was placed on one-to-one observation for behaviors. The Room Change Notification form indicated he was moved to a private room "for the health and safety of him and other residents."
CNA #3, interviewed the next day, said she checked on Resident #2 "because he punched someone" and to monitor his location because he wandered the halls. But like her colleagues, she didn't know what triggers caused him to become upset with other residents.
The resident's care plans contained detailed behavioral information that staff apparently weren't accessing. His mood/behavior plan, initiated in January and revised in November, documented that he would become physically aggressive when agitated by other residents and was at risk for increased confusion and frustration. The plan noted his history of telling other residents to get out of his way.
His cognitive care plan warned of increased confusion and frustration with his diagnosis and placement. The elopement plan identified him as a wandering risk related to being disoriented to place, with a history of attempting to leave the facility unattended.
The director of nursing told inspectors that staff could look at the Kardex, a staff directive tool, for information about triggers, behaviors and interventions. She said care plans should include resident-specific triggers and interventions for mood and behavior, explaining that knowing this information helped staff know what to look for, especially if they were new to the resident.
The DON said when residents had behavioral changes, these were discussed in morning interdisciplinary team meetings and care plans were updated. Staff were notified verbally of changes, and this information was expected to be passed from shift to shift.
But the reality on the floor told a different story.
The facility had already moved Resident #2 multiple times trying to manage his behaviors. Initially admitted to the secured unit, he was later moved off and given a roommate. When that roommate voiced concerns, the interdisciplinary team moved him again to room with Resident #1, hoping to prevent incidents.
Despite these proactive room changes, the September punch incident occurred anyway. Resident #2 was moved to a private room afterward.
CNA #3's description captured the disconnect between the detailed care planning and actual staff knowledge. She knew Resident #2 liked to walk the hallways and sometimes needed redirection to his room because he would get lost. She knew he had punched someone. But she couldn't identify what made him upset with other residents in the first place.
The inspection found that while the facility had comprehensive care plans addressing Resident #2's behavioral risks, the nursing aides providing his direct care remained unaware of the specific triggers that could prevent aggressive incidents.
Federal inspectors cited the facility for failing to ensure staff were knowledgeable about resident-specific behavioral interventions, despite having the information available in care plans and staff directive tools.
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 2025-12-01 including all violations, facility responses, and corrective action plans.