Falcon Heights Rehabilitation And Nursing Llc
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
was independent with activities of daily living (ADL).The MDS assessment revealed the resident did not have any behaviors or wandering tendencies. 2. Record reviewThe mood/behavior care plan, initiated 1/22/25 and revised 11/3/25, documented Resident #2 would become physically aggressive when agitated by other residents, he was at risk for increased confusion and frustration with the diagnosis and placement.
He had a history of telling other residents to get out of his way and he did not want them there. He verbalized not being happy in the facility and would wander into other resident's rooms. Interventions included redirecting the resident when he became agitated, placing the resident on one-to-one for safety, offering food and drink when he became agitated and 15-minute checks for elopement risk and behaviors.The cognitive care plan, initiated 12/27/24 and revised 3/31/25, documented Resident #2 was at risk of increased confusion and frustration with his diagnosis and placement. Interventions included, offering food or drink, change of environment when he became frustrated and to redirect when he became agitated. The elopement care plan, initiated 1/24/25 and revised 11/3/25, documented Resident #2 was an elopement risk/wanderer related to being disoriented to place, history of attempting to leave the facility unattended with impaired safety awareness. Resident #2 was on 15-minute checks for elopement risk and behaviors. Pertinent interventions included identifying patterns of wandering and completing an elopement/wander risk assessment quarterly and as needed. 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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FALCON HEIGHTS REHABILITATION AND NURSING LLC in COLORADO SPRINGS, CO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in COLORADO SPRINGS, CO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FALCON HEIGHTS REHABILITATION AND NURSING LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.