Falls City Care Center

Licensure Reference Number 175 NAC 12-006.02(H)Based on record reviews and interviews, the facility failed to report an allegation of abuse to the State Agency within the required timeframe for Resident 2. This affected 1 of 3 residents reviewed for abuse. The facility census was 56.Findings are:A record review of the facility's Abuse Prevention Plan last revised February 2023 revealed that the Administrator (ADM), Director of Nursing (DON), or Nursing Supervisor would make sure that a report was filed and an initial investigation begun immediately. The policy also stated that any allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of resident property should be reported to the State Agency immediately, within two hours if the event that caused the allegation included abuse or there was serious bodily harm, and within 24 hours if abuse was not involved and there was no serious bodily harm.A record review of Resident 2's Order Summary dated 06/25/2026 revealed the facility admitted the resident on 12/01/2025, and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interviews, the facility failed to investigate an allegation of abuse for Resident 2. This affected 1 of 3 residents reviewed for abuse. The facility census was 56.Findings are:A record review of the facility's Abuse Prevention Plan last revised February 2023 revealed that the facility would investigate all incidences such as falls, bruises, medication errors, and resident complaints.A record review of the facility's Skin Program Policy last revised March 2019 revealed that when a bruise or a skin tear was noted, a thorough assessment or comprehensive wound assessment sheet should be completed and documented.A record review of Resident 2's Order Summary dated 06/25/2026 revealed the facility admitted the resident on 12/01/2025, and the resident did not have a diagnoses of dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities).A record review of Resident 2's Quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04(D) The facility failed to provide a minimum of three nurse aides on each shift per the facility assessment and to ensure call lights were answered to meet the needs of the residents. This had the potential to affect all residents that resided in the facility. The total facility census was 49. Findings are: A record review of the Facility Assessment dated 07/01/2024 revealed the facility has an average daily census of 55 that requires 1-3 licensed nurses, 3-9 nurse aides, and 1-3 other nursing personnel. A record review of the facility's Posted Daily Staffing dated 05/04/2025 revealed three licensed nurses and no nurse aides on the day shift. A record review of the facility's Posted Daily Staffing for May 1st- May 31st, June 1, 2, and 3, 2025 revealed two nurse aides staffed on the night shift. A record review of the facility's Schedule Sheet dated May 2025 revealed two NA's scheduled for night shift every night. A record review of the facility's Past Calls for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY B. An observation on 06/02/25 at 10:42 AM revealed Resident 10 laying in bed with hair that appeared oily and shiny. During an interview on 06/02/25 at 10:43 AM Resident 10 revealed that (gender) cannot remember the last time (gender) had a bath or washed (gender) hair. An observation on 06/04/25 at 2:28 PM revealed Resident 10 lying in bed with hair that appeared oily and shiny. During an interview on 06/04/25 at 2:29 PM Resident 10 confirmed (gender) would like a bath at least once a week but cannot remember the last time (gender) took a bath or washed (gender) hair. Record review of Resident 10's admission Record revealed that the resident was originally admitted to the facility on [DATE]. Record review of Resident 10's Significant change Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 5/11/2025 revealed that the resident had a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.05(B) Based on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN-a form that lists the items or services that the facility expects Medicare will not pay for, along with an estimate of the costs for the items and services and the reasons why Medicare may not pay) and the Notice of Medicare Non-Coverage (NOMNC, a required notice allowing the resident to appeal the facility decision to end Medicare Part A coverage) was given to a beneficiaries at least two days prior to the end of covered services which affected 1 (Resident 9) of 4 sampled residents. The facility census was 49. Findings are: A review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form completed by the facility for Resident 9 revealed that the resident's Last Covered Day (LCD) for Medicare Part A services was 04/30/2025, and the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. A further review of the form…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(E)(i) Based on interview and record review the facility failed to ensure the individualized care plans covered the psychotropic (affects mental status) medication and discharge planning for 2 (Residents 26 and 48) of 4 sampled residents. The facility census was 49 Findings are: A record review of the facility's Care Planning policy and procedure with the revision date of 03/2019 revealed individual resident-centered care planning begins when the resident is admitted and doesn't end until the resident is discharged . The goal for the care plan is directly related to the resident's discharge plan. The physician's orders which include the resident medications are part of the care plan. Care plans should be updated between care conferences to reflect current care need of the individual resident as changes occur. A. A record review of Resident 26's Clinical Census dated 05/13/2025 revealed the resident was admitted to the facility on [DATE] A record review of Resident 26's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interview the facility failed to update the Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) to accurately reflect the fall interventions for 1 (Resident 10) of 3 sampled residents. The facility census was 49 at the time of survey. Findings are: Review of the facility's policy titled Fall Prevention and Response Policy dated revised April 2025 revealed that when a fall occurs the care plan will be updated with any new or updated fall interventions. Review of the facility's policy titled Care Planning dated revised March 2019 revealed that careplanning is constantly in progress and it begins the moment the resident is admitted to the facility and doesn't end until discharge or death. Record review of Resident 10's admission Record revealed that the resident was originally admitted to the facility on [DATE]. Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference 175 NAC 12-006.09(H)(i)(3) Licensure Reference 175 NAC 12-006.09(H)(iv)(3) Based on observations, interviews, and record reviews the facility failed to provide timely repositioning and incontinence care for 1 (Resident 2) of 2 sampled residents for dependent cares. The facility census was 49 at the time of survey. Findings are: Record review of facility policy titled Repositioning Policy and dated [DATE] revealed that repositioning is critical for a resident who is immobile or dependent upon staff for repositioning, for residents who are in bed should be on a every 2 hour repositioning schedule or alternate schedule based on resident assessment, and residents with a stage 1 or above pressure ulcer the every 2 hour repositioning schedule maybe inadequate. An observation on 06/02/25 at 10:02 AM revealed Resident 2 lying in bed on (gender) back with eyes closed and curtains closed and lights off. An observation on 06/03/25 9:13 AM revealed Resident 2 lying in bed on (gender) back with eyes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review the facility failed to use proper hand hygiene (cleaning) and use of personal protective equipment (PPE) when providing wound care for one (Resident 8) of two sampled residents. The facility census was 49. Findings are: A record review of the Handwashing/Hygiene policy and procedure with revision date of 01/2020 revealed hand hygiene needs to be completed before and after direct physical contact with a resident, before and after handling any dressing, and objects soiled during or after resident care. Hand hygiene should have been completed immediately after or as soon as possible following contact of such body areas with blood or other potentially infectious material. The use of gloves does not replace handwashing/hand hygiene. A record review of Glove Use with Resident Cares: Policy and Purpose with revision date of 03/2019 revealed the purpose was to provide guidelines for the use of gloves for resident and employee protection. The staff should remove soiled undergarments following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.04C2 Based on record interview and record review; the facility failed to ensure sufficient staffing related to 8-hour daily RN (Registered Nurse) coverage, this had the potential to affect all residents who reside in the facility. The facility identified a census of 52. Findings are: A record review of the staffing schedules for 5/1/24 through 5/20/24 revealed no 8-hour RN coverage on 5/12/24 and 5/16/24, but did reveal there was only 4 hours of RN coverage on 5/12/24. An interview with the facility Administrator on 05/23/24 at 8:07 AM confirmed that after pulling timecards it was found that the facility did not have RN coverage on 5/6/24 and 5/12/24 and only 4 hours of RN coverage on 5/11/24. A record review of the documents titled Facility Assessment Tool (used to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies) dated 6/5/23 revealed the following guidance related to RN coverage: Staffing plan 3.2 Federal law requires nursing homes to have sufficient staff to meet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.04 Based on record review and interviews; the facility failed to ensure that 5 of 5 reviewed nursing assistants (NA's) had completed 12 mandatory education hours annually, this had the potential to affect all residents who reside in the facility. The facility identified a census of 52. Findings are: A record review of the continuing education hours for 5 employees hired more than one year ago revealed that the following staff had received or completed the following education hours; -NA-K had 6.7 hours of continuing education completed in the last 12 months. -NA-L had 0.50 hours of continuing education completed in the last 12 months. -NA-M had 5.05 hours of continuing education completed in the last 12 months. -NA-N had 0.50 hours of continuing education completed in the last 12 months. -NA-O had 1.75 hours of continuing education completed in the last 12 months. An interview with the facility Administrator on 05/21/24 at 3:20 PM confirmed that Nursing Assistants who had been employed in the facility for more than 1 year had not completed 12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.09D2 Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 47) of 3 sampled resident's wound care was completed as ordered by the provider. The total facility census was 52. Findings are: A record review of Resident 47's Clinical Census dated 05/22/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 47's Medical Diagnosis dated 05/22/2024 revealed the resident had diagnoses of Type 2 Diabetes Mellites With Diabetic Chronic Kidney Disease (uncontrolled blood sugars that resulted in kidney disease), Secondary Malignant Neoplasm of Bone (bone cancer) Weakness, and lung disorders. A record review of Resident 47's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 05/02/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) of 12 of 15 which indicates the resident was moderately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.17B Licensure Reference Number 175 NAC 12.006.17D Based on observations, interviews, and record review; the facility failed to ensure all infection control measures were followed during wound care for 1 (Resident 47) of 3 sampled residents, ensure 1 (Resident 54) of 1 sampled resident's nebulizer kit (used to deliver liquid medication to the lungs) and mask were cleaned after each treatment, and failed to perform hand hygiene between gloves changes while providing catheter cares for 1 (Resident 41) of 1 sampled resident. The total facility census was 52. Findings are: A. A record review of the facility's Handwashing/Hygiene policy with a revision dated of Jan. 2020 revealed hand hygiene needed to be completed before donning (putting on) and after removal of gloves. A record review of Resident 47's Clinical Census dated 05/22/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 47's Medical Diagnosis dated 05/22/2024 revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 12-007.04D Based on observation and interview, the facility failed to ensure the ventilation systems were operational in 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) occupied resident's bathrooms on the 300 hallway of the facility. The facility identified a census of 55. Findings are: Observation on 5/22/23 at 9:00 AM of room [ROOM NUMBER]'s bathroom revealed the vent did not draw a 1 square ply of toilet paper when tested for ventilation. Observation on 5/22/23 at 9:10 AM of room [ROOM NUMBER]'s bathroom revealed the vent did not draw 1 square of ply of toilet paper when tested for ventilation Interview on 5/23/23 at 10:54 AM with Maintenance Director revealed room [ROOM NUMBER] and 304 bathroom ventilation systems were not functioning. Interview on 5/23/23 at 10:54 AM with the Administrator confirmed the ventilation system was not functioning in room [ROOM NUMBER] and 304 bathrooms.