Deficiency Records for Falls City Nursing and Rehabilitation Center
Updated as of February 01, 2023
This is not the most recent data for Falls City Nursing and Rehabilitation Center. For the most recent information, click here.
A list of the most recent deficiencies for Falls City Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-06 | 2022-07-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-07-06 | 2022-07-30 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-07-06 | 2022-07-30 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-07-06 | 2022-07-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-06 | 2022-07-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-06 | 2022-07-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-06 | 2022-07-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-06 | 2022-07-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-06 | 2022-07-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-06 | 2022-07-30 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-06 | 2022-07-30 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2022-07-06 | 2022-07-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-06-28 | 2022-07-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-06-28 | 2022-07-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-28 | 2022-07-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-28 | 2022-07-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-06-28 | 2022-07-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-28 | 2022-07-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-06-28 | 2022-07-30 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-06-28 | 2022-07-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-28 | 2022-07-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-16 | 2022-03-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-16 | 2022-03-04 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-02-16 | 2022-03-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-16 | 2022-03-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-16 | 2022-03-04 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-07-01 | 2021-07-30 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-07-01 | 2021-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-01 | 2021-07-30 | Y |
| Report COVID19 data to residents and families. | Health | 2021-02-04 | 2021-03-10 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-02-04 | 2021-03-10 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-02-04 | 2021-03-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-02-04 | 2021-03-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-02-04 | 2021-03-10 | N |
| Meet other general requirements. | Fire Safety | 2021-02-01 | 2021-03-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-02-01 | 2021-03-10 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-02-01 | 2021-03-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-02-01 | 2021-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-01 | 2021-03-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-02-01 | 2021-03-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-02-01 | 2021-03-10 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2021-02-01 | 2021-03-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-09-03 | 2020-10-09 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-09-03 | 2020-10-09 | Y |
| Assess the resident when there is a significant change in condition | Health | 2020-09-03 | 2020-10-09 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-09-03 | 2020-10-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-06-16 | 2020-08-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-07-05 | 2019-09-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-05 | 2019-09-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-04 | 2019-08-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-04 | 2019-08-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-07-04 | 2019-08-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-07-04 | 2019-08-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-07-04 | 2019-08-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-07-04 | 2019-08-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-04 | 2019-08-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-04 | 2019-08-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-04 | 2019-08-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-07-05 | 2019-08-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-05 | 2019-07-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-05 | 2019-07-29 | N |
| Meet other general requirements. | Fire Safety | 2019-07-05 | 2019-07-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-05 | 2019-07-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-05 | 2019-07-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-07-05 | 2019-07-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-05 | 2019-07-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-07-05 | 2019-07-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-05 | 2019-07-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-05 | 2019-07-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-05 | 2019-07-05 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2019-07-05 | 2019-07-05 | N |
