Falling Water Healthcare Center

Inspectors wroteBased on observation, interview, record review, and review of facility policy the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect 87 residents out of 91 residents who received food from the kitchen. Four residents (Resident #4, #37, #53, and #91) were identified as not receiving anything by mouth and received no food from the kitchen. The facility census was 91.

Inspectors wroteBased on record reviews and interviews the facility did not ensure care conference meetings were offered or held for residents #6, #22, #41 and #80. This affected four residents (#6, #22, #41 and #80) of four residents reviewed for participation in care planning. The census was 91. 1. Review of the medical record for Resident #6 revealed an admission date of 10/27/24. Diagnoses included atrial fibrillation, hypertension and anemia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact. Review of the MDS report from March 2025 to July 2025 revealed Resident #6 had quarterly assessments completed on 03/15/25 and 06/13/25. Review of the miscellaneous tab in the electronic medical record (EMR) revealed the last documented care plan meeting was Resident #6's 72-hour meeting at admission. An interview on 07/28/25 at 2:29 P.M. [...]

Inspectors wroteBased on resident record review, observations, resident interview, staff interview, and facility policy review, the facility failed to ensure dependent residents had access to call lights. This affected one resident (#9) of 24 residents reviewed for call lights. The facility census was 91.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #68 had access to his social security allowance as required. This affected one resident (#68) of five residents reviewed for funds. The facility census was 91.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had accurate advance directive orders and information in place throughout the medical record for Resident #86. This affected one resident (#86) out of 24 residents reviewed for advanced directives. The facility census was 91.

Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policy, the facility failed to administer medications as ordered. There were two errors observed out of 28 opportunities for a medication error rate of 7.14 percent (%). This affected one resident (#10) out of seven residents observed for medication administration. The facility census was 91.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with foods to accommodate their allergies and preferences during meals. This affected three residents (#13, #40, and #46) of three reviewed for food/nutrition. The facility census was 91.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation, record review and interview, the facility failed to provide adequate care and services to prevent a second degree burn on the Resident #68's right hand. Actual Harm occurred on 12/03/24 when Resident #68 sustained a second degree burn to her right dorsal hand after spilling hot noodle soup onto her right hand. The soup had been heated in a microwave by nursing staff at an unknown hot temperature and then handed to the resident who was standing in the area. This affected one resident (#68) of three residents reviewed for accidents/hazards.

Inspectors wroteBased on closed record review and interview, the facility failed to implement comprehensive, individualized and effective behavioral health interventions for Resident #107, who was diagnosed with dementia and had a history of inappropriate sexual behaviors, to prevent additional inappropriate sexual behaviors from occurring. This affected one resident (#107) of nineteen residents who resided on the SMCU.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and the facility submitted Payroll Based Journal (PBJ) tracking information, the facility failed to ensure the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 108 residents residing in the facility.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure notification of a resident's change in condition and subsequent hospitalization. This affected one resident (#31) of one resident investigated for notification. The census was 108.

Inspectors wroteBased on interview and record review, the facility failed to ensure dependent residents received routine showers. This affected two residents (Resident #13 and #31) of three residents (Residents #13, #31, and #70) reviewed for activities of daily living (ADLs). The facility census was 108.

Inspectors wroteBased on observation, record review, interview, and policy review the facility failed to ensure infection control measures were followed during medication administration. This affected one of four residents observed during medication administration, Resident (#59). The census was 108.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, resident and staff interview, review of medial imaging results, review of staff statements, and review of facility corrective action, the facility failed to provide adequate and sufficient assistance during personal care to prevent a fall with major injury for Resident #30. Actual harm occurred on 05/28/24 when Resident #30, who required staff assistance (care planned to require two-person assistance and/or substantial to maximal assistance with activities of daily living (ADLs)) sustained a fall out of bed resulting in a fractured left hip. At the time of the incident, one (1) staff member was providing care to the resident. This affected one (#30) of three residents reviewed for falls. The census was 99. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to maintain a medication error rate of less than five percent (%). The medication error was 12.00% due to three observed medication errors for 25 medication administration opportunities. This affected two (Residents #9 and #42) of four residents observed for medication administration. The facility census was 94 residents.

Inspectors wroteBased on medical record review, staff interview, review of the emergency medical service report (EMS), and review of the facility policy, the facility failed to ensure the resident medical record included accurate documentation. This affected one (Resident #95) of three residents whose records were reviewed for medical record documentation. The facility census was 94 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure personal protective equipment (PPE) was worn while providing care to a resident on contact precautions. This affected 10 of 10 residents who received care provided by State Tested Nurse Aide (STNA) #209, Residents #5, #24, #37, #48, #54, #57, #63, #69, #76 and #77.

Inspectors wroteBased on observation, interview, record and document review, the facility failed to ensure all portions of the call light system were functional and repairs/replacements were completed timely. This affected four residents (#28, #109,#124, and #89) in three of 32 room environments observed. Facility census was 112.

Inspectors wroteBased on observation and interview the facility failed to ensure Resident #10 was treated with dignity and respect during dining. This affected one of nine residents (#2, #10, #35, #37, #39, #54, #62, #74 #84) who ate their meal in the second floor dining room. The facility census was 112.

Inspectors wroteBased on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) 3.0 assessments for two (Residents #29 and Resident #52) of twenty-eight residents reviewed for assessments.