Falls City Care Center

Inspectors wroteLicensure Reference Number 12-006.04(F)(i) Based on record review, and interview, the facility failed to notify the resident's physician of a change in condition, and failed to notify family representative for 1 resident (Resident 2) of 5 sampled residents a change in condition. The facility census was 56.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 (C)(ii) Based on record reviews and interviews, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities within 14 days of a significant change for 2 (Resident 2 and 3) of 5 residents sampled. The facility census was 56.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on record review and interview the facility failed to identify causative factors for one (Resident 1) of 5 sampled residents and the facility failed to put in new interventions to prevent falls for one (Resident 1) of 5 sampled residents. The facility census was 56Finding are: A record review of admission Record revealed Resident 1 was admitted to the facility on [DATE] with the diagnosis of Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Injuries of left hip, Hypertension (high blood pressure), Dementia, and Fracture of Superior Rim of left Pubis (pelvic fracture). A record review of Resident 1's progress notes dated 7/14/26 revealed Resident 1 had a fall. Upon assessment resident is lying on left side next to (gender) bed in fetal position. [...]

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteB. 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]. [...]

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.