Falling Water Healthcare Center

In the surveyor’s words

From the most serious findings on record at Falling Water Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 19, 2024

  THE 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. […]

• Actual harm, isolatedF689Jun 10, 2024

  THE 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. […]

• No harm, potential for more than minimal, widespreadF812Aug 4, 2025

  Based 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.Findings include: Observation on 07/28/25 from 8:22 A.M. through 8:36 A.M. with Registered Dietitian (RD) #950 revealed that in the dry storage area, there was a bottle of vanilla with a cracked lid. In the cooking area, the large floor mixer had dried batter on the back splash and the top of the mixing mechanism, and microwave had dried food splatter inside. […]

• No harm, potential for more than minimal, widespreadF727Sep 25, 2024

  THE 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. Findings include: Review of the PBJ Staffing Data Report form submitted from 10/01/23 to 12/31/23 revealed on the following dates submitted for the first quarter of the fiscal year 2024, the facility was low on RN hours in the building on 10/01 (Sunday); 10/14 (Saturday); 10/15 (Sunday); 10/28 (Saturday); 10/29 (Sunday); 11/11 (Saturday);… […]

• No harm, potential for more than minimal, widespreadF838Dec 17, 2021

  Based on record review and interview, the facility failed to develop a staffing plan identifying the number of licensed nurses and nursing assistants needed each 24 hours to meet the acuity needs of the residents. This had the potential to affect all 103 residents living in the facility. Findings include: Record review was conducted of the facility document titled Facility Assessment Tool, date updated 10/01/2021. The assessment indicated the average census was 107. An activity of daily living grid was listed on the assessment and indicated the majority of the resident population required limited to extensive assistance by staff or was dependent on staff for bathing, bed mobility, transfers, eating, dressing, personal hygiene and toileting. […]