Falcon Heights Rehabilitation And Nursing Llc
FALCON HEIGHTS REHABILITATION AND NURSING LLC in COLORADO SPRINGS, CO — inspection on December 1, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the electronic medical record (EMR) revealed the resident had been admitted to the secured unit.The progress note, dated 8/13/25, documented Resident #2 became agitated and aggressive towards another resident. He was put on one-to-one observation for behaviors.
The 9/9/25 Room Change Notification form indicated Resident #2 was moved to a private room for the health and safety of him and other residents. III.
Staff interviewsCertified nurse aide (CNA) #2 was interviewed 11/4/25 at 1:18 p.m. CNA #2 said she got information regarding the residents when she did a walk through of the unit with the staff going off shift.
She said she was not aware of where to look for specific information regarding triggers for resident behaviors.
She said she asked the nurse if she had questions. CNA #1 was interviewed 11/4/25 at 1:27 p.m. CNA #1 said she worked on Resident #2's unit. He said he was usually worked another hall and was not aware of any specific behavior triggers which would cause Resident #2 to act aggressively. He said the 15-minute checks were to monitor the resident's location because he wandered. CNA #1 said he was not aware of the incident on 9/9/25.
The director of nursing (DON) was interviewed 11/5/25 at 10:11 a.m.
The DON said when Resident #2 was moved off the secured unit he was placed with a roommate.
The DON said the roommate had verbalized concerns with Resident #2, so the interdisciplinary team (IDT) decided to move Resident #2 to another room, with Resident #1, before there were any incidents.
The DON said staff could look at the Kardex (staff directive tool) for information about triggers, behaviors and interventions.
The DON said that care plans should include resident specific triggers and interventions for mood and behavior.
The DON said knowing this information assisted staff on what to look for especially if they were new to the resident.
She said if a resident had a change in behavior this is discussed in the morning IDT meeting and the care plans were updated with the new behavior and interventions.
The DON said the staff were notified verbally of changes and this information was expected to get passed on from shift to shift. CNA #3 was interviewed 11/5/25 at 11:09 a.m. CNA #3 said she checked on Resident #2 because he punched someone and to monitor his location because he wandered up and down the halls.
She said she did not know what triggers Resident #2 to become upset with other residents.
She said Resident #2 liked to walk the hallways and sometimes needed redirection to his room because he would get lost.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.