Falls City Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Falls City Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF580May 7, 2026

  Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record reviews and interviews, the facility failed to notify the resident's physician of a change in condition, failed to report a fall that delayed in the resident medical care for one sampled resident and failed to follow standards of practice after an injury to the head for one sampled resident (Resident 1). The facility census was 42.Findings are:A record review of the admission Record with a printed date of 5/6/26 revealed that Resident 1 was admitted to the facility on [DATE] with the diagnosis of Dementia - severe with anxiety and Behavioral Disturbance behaviors, which included agitation, aggression, and wandering, often caused by fear, overstimulation, or unmet needs, Depression (characterized by persistent sadness,… […]

• Actual harm, isolatedF686Feb 16, 2022

  Licensure reference: 175 NAC 12-006.09D2b Based on record review and interview, the facility failed to identify and evaluate a pressure sore for 1 [Resident 3] of 4 sampled residents with pressure sores. The facility had a total census of 32 residents. Findings are: A review of Resident 3's Admission assessment dated [DATE] revealed a 1.2 x 1.2 cm [centimeter] reddened area to the resident's left heel. A review of Resident 3's Care Plan included a goal initiated on 10/4/21 to have the left heel wound heal without complications prior to the next review. […]

• No harm, potential for more than minimal, widespreadF812Jul 31, 2025

  Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review, the facility failed to ensure the chemical low-temperature (temp) dish machine reached a minimum temp of 120 degrees Fahrenheit (F)(a temperature scale) during all wash and rinse cycles and failed to ensure spoiled vegetables from the garden were disposed of to prevent foodborne illness. This had the potential to affect 38 residents that consumed food from the kitchen. The total facility census was 39. Findings are:A.A record review of the facility's undated Dish Machine Temperature Log policy revealed the Dietary Manager (DM) would train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process. […]

• No harm, potential for more than minimal, widespreadF761Mar 25, 2025

  Licensure Reference Number 175 NAC 12.006.12(D)(i) Based on observations, interviews and record review, the facility failed to secure all medications in a locked storage area and to limit access to authorized personnel. The facility identified a census of 41. Findings are: Record review of facility's undated Drug Storage Policy revealed: It is the policy of this facility to ensure the proper and safe storage of drugs and biologicals. Drugs and/or biologicals should not be left unsecured/unattended. Medication and treatment carts will be kept locked when unattended. Observation on 3/25/25 at 9:00 AM revealed a medication cart containing resident's medications, located near the nurse's station, was unlocked and unattended by staff. […]

• No harm, potential for more than minimal, widespreadF880Jul 6, 2022

  Licensure Reference Number 175 NAC 12-006.17A(2) Licensure Reference Number 175 NAC 12-006.17A(4) Licensure Reference Number 175 NAC 12-006.17B Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed to ensure staff and visitors' COVID-19 screening was completed and evaluated prior to entrance into facility, failed to ensure signage was posted indicating what Personal Protective Equipment (PPE) staff and visitors were to be use for a Modified Yellow Isolation Zone and a Gray Zone isolation room, failed to ensure staff and visitors donned (put on) the correct PPE for specific Isolation Zones, failed to ensure staff performed hand hygiene between residents during medication delivery, and failed to ensure staff wore a surgical mask… […]