Waters of Clifty Falls, The

In the surveyor’s words

From the most serious findings on record at Waters of Clifty Falls, The, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 18, 2025

  Based on observation, interview, and record review, the facility failed to prevent an accident during a transfer resulting in skin tears requiring sutures for 1 of 3 residents reviewed for accidents. (Resident B)Findings included:During an interview, on 11/18/2025 at 9:27 A.M., Certified Nurse Aide (CNA) 4 indicated Resident B had required a full body mechanical lift for transfers for a while. The resident was not interviewable and was dependent on staff for all other care. Prior to the resident requiring a full body lift she required two physical staff members assistance to pivot and transfer. […]

• No harm, potential for more than minimal, patternF583Jun 4, 2025

  3. During a continuous observation, on 05/29/25 from 1:38 P.M. through 1:44 P.M. the following was observed: - At 1:38 P.M., a computer screen was opened on Medication Cart 1 on the 100 Hallway that was sitting between resident rooms [ROOM NUMBERS]. The screen had Resident 66's name and medication list visible. - At 1:39 P.M., a resident in a wheelchair propelled by the cart and looked towards the computer and kept going, - At 1:40 P.M., LPN 8 who had been standing at Medication Cart 2 outside of room [ROOM NUMBER], approximently ten feet from Medication Cart 1, walked into room [ROOM NUMBER] next to Medication Cart 1 out of visible sight of both Medication Carts 1 and 2. The LPN did not close the open computer screen on Medication Cart 1. […]

• No harm, potential for more than minimal, patternF684Jun 4, 2025

  Based on record review, interview, and observation, the facility failed to follow physician's orders related to cardiac medication hold parameters and follow manufacturer's guidelines related to insulin pen usage for 5 of 20 residents reviewed for Quality of Care. (Residents 2, 93, 7, 78, and 29) Findings include: 1. Resident 2's clinical record was reviewed on 06/04/25 at 10:17 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/20/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, hypertension, and chronic kidney disease. An open-ended physician's order, with a start date of 01/31/25, indicated the nursing staff were to administer the resident's Metoprolol 12.5 milligrams (mg) daily at 9:00 A.M. and 9:00 P.M. […]

• No harm, potential for more than minimal, patternF812Jun 4, 2025

  Based on observation and interview, the facility failed to store foods appropriately to prevent contamination for 1 of 2 kitchen observations. Findings included: 1. The initial kitchen tour was conducted on 05/29/25 at 10:48 A.M., and the following was observed: - A large clear plastic container sitting on a metal shelf contained flour. The lid was ill-fitting and not designed for the container, - A large clear plastic container sitting on a metal shelf contained sugar with a plastic scoop sitting inside. During an interview on 05/29/25 at 10:50 A.M., Dietary Aide 13 indicated the scoop should not have been left in the sugar and the lids were not the right ones for the containers. […]

• No harm, potential for more than minimal, patternF880Jun 4, 2025

  3. The clinical record for Resident 52 was reviewed on 06/03/25 at 2:08 P.M. A Quarterly MDS assessment, dated 02/24/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, a stroke, depression, obesity, and weakness. An open-ended physician's order, with a start date of 06/02/25 at 2:31 P.M., indicated the resident was in enhanced barrier precautions for a pressure wound. During an observation, on 06/03/25 at 2:09 P.M., the resident's door had a sign on it that indicated staff were to STOP and that the resident was in ENHANCED BARRIER PRECAUTIONS. Staff must wear a gown and gloves for high contact resident care activities, including but not limited to, Wound Care: any skin opening requiring a dressing. […]