Fall Creek Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for 2 of 5 residents (Resident #1 and #2) reviewed for ADLs. The facility failed to provide nail care to Resident #1, leaving fingernails on both hands long, jagged, split and dirty. The facility failed to provide nail care to Resident #2, leaving fingernails on both hands long, jagged and dirty. This failure could place residents at risk of infection, injury, pain, deterioration of health and a diminished quality of life. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #74) reviewed for comprehensive care plans. -The facility failed to provide Resident #74 with a comprehensive resident centered care plan to address her pressure ulcers. This failure could place residents at risk of not having their specific care needs met and from reaching their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for 1 of 7 residents (Resident # 2) reviewed for resident rights.-The facility failed to ensure Resident #2, or her family member were provided with written notice before the resident was moved to a different room on 05/07/2026. This failure could place residents at risk for a decline in their well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed to ensure Resident #2 was free from physical abuse when Resident #1 hit her leg on 3/16/26. This failure could place residents at risk of emotional distress, fear, decreased quality of life, and abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the interdisciplinary team reviewed and revised the resident's comprehensive care plan after each assessment for 1 (Resident #1) of 5 residents reviewed for care plan revisions. The facility failed to update and add interventions to Resident #1's care plan regarding physical behaviors toward other residents, including Resident #2. This failure could place residents at risk of injury.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 4 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for infection control, in that: - CNA J failed to wear PPE for EBP, when she provided incontinence care to Resident #1.- CNA H failed to sanitize her hands and change her gloves before putting a new brief on Resident #2 and the resident was on contact precautions for MRSA in the urine.- CNA M failed to wear PPE for EBP, when she provided incontinence care to Resident #3.- CNA G failed to wear PPE for EBP, when she provided incontinence care to Resident #4. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a resident has a right to personal privacy and confidentiality of his or her personal and medical records for 2 of 3 computers (LVN T and LVN C). The facility's computers were left open and unattended at the nurse's station with residents' personal medical information was visible to anyone who passed by on, 05/29/2025 while the user of the computer was on the hallway. The failure could place residents at risk of having their private information changed, viewed and not kept secure.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #26) of 2 residents reviewed for respiratory care. The facility failed to ensure Resident #26's oxygen tubing was changed every seven days as was ordered and per the facility's policy. The failure could place residents at risk of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities which involved 2 of 8 residents (Residents #39 and #30) and 2 of 7 staff (MA G and MA C) reviewed for medication administration. 1. The facility failed to ensure MA G did not administer Chewable Aspirin to Resident #39 instead of delayed release aspirin as ordered by the MD. 2. The facility failed to ensure MA C did not administer Divalproex 250 mg to Resident #30 after it was discontinued by the MD on 5/22/25. 3. The facility failed to ensure MA C did not administer one Vitamin D 1000 IU tablet to Resident #30 instead of two as ordered by the MD. [...]

Inspectors wroteBased on interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 12 Residents (CR #1 and Resident #26) reviewed for care plans. The facility failed to identify CR #1's diagnosis of Ventriculoperitoneal Shunt (a small plastic tube that is used to drain the cerebrospinal fluid from the brain into the space of the abdomen) in her care plan. The facility also failed to ensure that Resident #26's care plan included information regarding his oxygen that was ordered 5/7/25. The failure could place residents at risk of not having their needs met or inability of staff to identify a change of condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 2 (Residents #377 and #378) of 10 residents reviewed for Activities of Daily Living. The facility failed to provide Residents #377 and #378 with adequate services to maintain personal hygiene. This failure could place residents at risk of diminished quality of life, decreased self-esteem or skin breakdown.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to immediately inform and consult with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) ensure the severity of changes in condition were reported to physician for resident (Resident #1) who required colostomy, urostomy, or ileostomy for 1 of 4 residents reviewed for change in condition in that: 1. The facility failed to when notify the NP of the severity of the change in condition and the difficulties the nursing staff were having keeping Resident #1's ileostomy system secure and in place. 2. The facility failed to obtain a new physician order due to resident's change in condition causing skin breakdown. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who required colostomy, urostomy, or ileostomy services received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 residents (Resident #1) reviewed for ostomy care in that: 1. The facility failed to ensure Resident #1's ileostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, to divert waste from the small intestine), wafer (the piece of the pouching system that sticks to your body and holds your pouch in place and should help protect the skin around your stoma from damage) and bag were in place. 2. The facility failed to empty Resident's #1's ileostomy bag timely and remain free from leakage. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 3 of 8 residents (Resident #1, Resident #2 and Resident #3) reviewed for resident rights. 1. The facility failed to ensure Resident #1's ileostomy (a surgical technique that uses small incisions and specialized instruments, including a laparoscope (a thin tube with a camera), to examine and treat conditions within the abdomen) bag was empty timely to avoid leakage. 2. The facility failed to ensure Resident #1 was cleaned immediately after his ileostomy bag leaked. 3. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs, for 1 (CR #1) of 5 Residents reviewed for care plans in that: The facility failed to develop a comprehensive person-centered care plan for CR #1 to address the risk for falls. This failure placed residents who were fall risk at risk of serious harm and injury. An Immediate Jeopardy (IJ) was identified on 1/16/2025. The IJ template was provided to the Administrator and DON on 1/16/2025 at 3:45pm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (CR#1) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure precautionary interventions in place CR #1, who was a known fall risk that resulted in falls with serious injuries and multiple hospitalization. An Immediate Jeopardy (IJ) was identified on 1/16/2025. The IJ template was provided to the Administrator and DON on 1/16/2025 at 3:45pm. While the IJ was removed on 1/18/2025 at 4:29 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of eight residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure Resident #1 was not left unattended in her restroom for more than seven hours. The noncompliance was identified as PNC. The IJ began on 2/14/2024 and ended on 2/15/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm, malnutrition, missed medications, pressure injury, fatigue, and death.

Inspectors wroteBased on interviews and record review the facility failed to ensure the resident was free from misappropriation of property for two of six residents (Resident #4 and Resident #5) and six of six (CR #2, CR #3, CR #6, CR #7, CR #8, and CR #9) closed records reviewed for misappropriation of property. 1. The facility failed to ensure that unknown staff did not misappropriate Resident #4, Resident #5, CR #2, CR #3, CR #6, CR #7, CR #8, and CR #9's controlled medications in November of 2023. 2. The facility failed to have a system in place to identify drug diversion of controlled substances. These failures could place residents at risk for misappropriation of medications and uncontrolled pain. The noncompliance was identified as PNC. The IJ began on 11/20/23 and ended on 11/21/2023. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for two of six residents (Resident #4 and Resident #5) and six of six (CR #2, CR #3, CR #6, CR #7, CR #8, and CR #9) closed records reviewed for pharmacy services. 1. The facility failed to ensure one former resident (CR #6) received the correct medication. CR #6's medication labels were switched. 2. The facility failed to ensure discontinued medication was discarded and controlled medication was destroyed according to standard protocols as nine medication packages were altered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide 2 of 3 residents (Resident #7 and #39) food in a form to meet their needs: Residents #7 and #39 were not provided a nutritional supplement as ordered. This failure places residents at risk of experiencing nutritional deficiencies. Resident # 7 Record review of Resident #7's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with abnormal weight loss, vitamin deficiency. Record review of Resident #7's care plan, dated 01/08/2024 revealed Resident #7 was triggered for significant /unexpected weight loss due to many food dislikes, diet restrictions and is at risk for further weight fluctuation. The goal associated with this risk was for Resident #7 to have weight stabilized by target date April 3, 2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop the comprehensive person-centered care plan with services furnished to maintain the resident's highest practicable physical well-being for 1 of 18 residents, (Resident #23), in that: - Resident #23's care plan was not updated to reflect the resident's need for a fall mat. these failures placed residents at risk of not receiving adequate care.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for two (Nurse Medication Cart 600 hall, Medication Aide Cart 400/500/600 halls) of six medication carts reviewed for storage of medications. -The facility failed to ensure the Nurse Medication Cart 600 hall and Medication Aide Cart 400/500/600 Halls was secured when unattended. These failures could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and the medications provided (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to [NAME] the needs of medications stored in 1 Medication Cart (600 hall) of 3 reviwed for medication storage. -The facility failed to ensure Nurse cart medication cart 600 hall did not store medications with punctured or torn backs. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.

Inspectors wroteBased on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.