Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Falls City Care Center during CMS and state inspections, most recent first.
The facility did not maintain the minimum required number of nurse aides per shift, resulting in prolonged call light response times and missed resident care, such as regular bathing for a resident with a wound. Staff and leadership confirmed that inadequate staffing led to delays in answering call lights and providing essential care, with no formal tracking or action plans in place to address these issues.
Two residents did not receive bathing according to their preferences, with one resident not having a bath for at least a month and another unable to recall their last bath, both due to staff shortages and lack of proper documentation. Care plans lacked bathing interventions or preference assessments, and staff confirmed that regular weekly baths were not consistently provided. The facility did not have a formal bathing policy, and documentation of baths and refusals was incomplete.
A resident was not given the required SNF ABN and NOMNC at least two days before the end of Medicare Part A coverage, as both notices were signed on the last covered day instead. The Social Services Director confirmed the notices were not provided within the required timeframe.
Two residents' care plans did not address all required needs: one resident's plan omitted prescribed antidepressant medications despite a diagnosis of major depressive disorder, and another resident's plan failed to include discharge planning even though a discharge order was present. The DON and SSD confirmed these omissions during interviews.
A resident with a history of falls and moderate cognitive impairment experienced a fall and was sent to the ER, but the facility did not update the Comprehensive Care Plan (CCP) with new fall interventions as required by policy. The DON confirmed that no new interventions were added to the CCP following the incident.
A resident who was dependent for ADLs and had a pressure ulcer was not repositioned or provided incontinence care as required by their care plan and facility policy. Observations showed the resident remained in the same position for extended periods and wore heavily saturated briefs, with staff confirming lapses in care and the DON acknowledging the lack of a wound care policy.
Staff failed to follow infection control protocols during wound care for a resident with a stage 2 pressure ulcer, including not wearing a gown, not changing gloves, and not performing hand hygiene between tasks. The LPN used the same gloves for wound care and peri care, and exposed the wound to a soiled brief, contrary to facility policy and best practices.
The facility failed to ensure sufficient staffing related to 8-hour daily RN coverage, affecting all residents. A review of staffing schedules revealed no 8-hour RN coverage on multiple days and only partial coverage on others. The facility Administrator confirmed these findings, and a review of the Facility Assessment Tool highlighted the federal requirement for 8-hour daily RN coverage.
The facility failed to ensure that five nursing assistants completed the mandatory 12 hours of continuing education annually. Record reviews and interviews confirmed that the NAs did not meet the required education hours, and one NA was unaware of the requirement. This deficiency had the potential to affect all 52 residents in the facility.
A resident with multiple medical conditions, including diabetes and bone cancer, did not receive wound care as ordered by the physician. An LPN misread the order and failed to apply Betadine to the blistered areas on the resident's lower extremities, leading to a deficiency in care.
The facility failed to follow infection control measures during wound care, nebulizer kit cleaning, and catheter care. An LPN did not perform hand hygiene between glove changes and used a contaminated dressing pad, while another resident's nebulizer kit was not cleaned after each use. Additionally, a nurse aide did not perform hand hygiene between glove changes during catheter care.
Failure to Maintain Minimum Nurse Aide Staffing and Timely Call Light Response
Penalty
Summary
The facility failed to provide the minimum required number of nurse aides on each shift as outlined in its own facility assessment, which specified a minimum of three nurse aides per shift. Staffing records revealed that on several occasions, including the entire month of May and into June, only two nurse aides were scheduled and present on night shifts, and on at least one day shift, there were no nurse aides present. This staffing shortfall resulted in prolonged call light response times, with multiple documented instances of call lights remaining unanswered for over 30 minutes, and in some cases, exceeding an hour. Observations and interviews confirmed that call lights were not answered within the facility's expected timeframe of 5-15 minutes, and staff acknowledged that the lack of adequate staffing contributed to these delays. Additionally, the insufficient staffing impacted resident care, as evidenced by a resident who did not receive weekly baths as preferred and required, with documentation and interviews confirming that the resident had not been bathed for at least a month. The resident also had a wound on the leg and was informed by staff that bathing would help, but the lack of available staff prevented this care from being provided. Staff interviews further corroborated that baths were not being completed regularly due to staffing shortages. The Director of Nursing confirmed that the facility did not track call light response times or have action plans to address the delays, and both the Administrator and DON acknowledged that the staffing levels and response times were not acceptable.
Failure to Provide Bathing per Resident Preference Due to Staffing and Documentation Issues
Penalty
Summary
The facility failed to honor and facilitate resident self-determination regarding bathing preferences for two residents. For one resident with polyneuropathy and restless leg syndrome, who was cognitively intact and required maximum assistance for bathing, there were no care plan interventions or social service assessments addressing bathing preferences. Bathing logs and schedules showed infrequent baths, and the resident confirmed not having a bath for at least a month, attributing this to staff shortages. Staff interviews corroborated that baths were not being provided weekly as expected, and the Director of Nursing confirmed that bath logs were discarded after documentation in the electronic medical record. The facility also lacked a specific bathing policy. Another resident, who required supervision or touching assistance with activities of daily living and had a moderate cognitive impairment, was observed with oily hair and could not recall the last time they had a bath or washed their hair. Bathing logs indicated only one or two baths per month, and there was no documentation of bed baths or refusals in the progress notes. The resident's care plan did not include bathing interventions or preferences, and staff interviews confirmed that there was not a daily bath aide scheduled and that staffing shortages impacted the ability to provide regular baths. Throughout the review, it was confirmed by multiple staff, including the Administrator and DON, that the facility did not have a formal bathing policy and that resident preferences for bathing were not consistently assessed or care planned. Documentation of bathing and refusals was inconsistent, and staffing limitations were cited as a reason for not meeting the expected frequency of weekly baths based on resident preferences.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a resident with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) at least two days prior to the end of Medicare Part A covered services. Record review showed that the resident's last covered day for Medicare Part A was 04/30/2025, and the facility initiated discharge from Medicare Part A services before benefit days were exhausted. Both the SNF ABN and NOMNC were signed electronically by the resident on the last covered day, with no date recorded for the Social Services Director's initials. An interview with the Social Services Director confirmed that the required notices were not provided within the mandated timeframe.
Care Plans Lacked Psychotropic Medication and Discharge Planning
Penalty
Summary
The facility failed to ensure that individualized care plans addressed all of the residents' needs, specifically omitting psychotropic medication management and discharge planning for two residents. For one resident with multiple diagnoses including major depressive disorder, hypertension, diabetes, and acute kidney failure, the care plan did not include the prescribed antidepressant medications, despite physician orders for Celexa and Remeron. The Director of Nursing confirmed that medications were not addressed in the care plan as required. For another resident with diagnoses such as hypertension, low back pain, muscle weakness, and unsteadiness, the care plan did not include the resident's discharge plan, even though there was a physician order for discharge to an assisted living facility. The Social Service Director confirmed that the discharge plan was not documented in the care plan. These omissions were identified through record review and staff interviews, and were not in accordance with the facility's care planning policy.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the Comprehensive Care Plan (CCP) to accurately reflect new fall interventions for a resident following a fall incident. According to the facility's Fall Prevention and Response Policy, the care plan should be updated with any new or revised fall interventions after a fall occurs. Record review showed that the resident, who had a history of falls and moderate cognitive impairment, experienced a fall on 5/7/2025, resulting in being sent to the emergency room. Despite this incident, no new fall interventions were identified or added to the resident's CCP. Further review of the resident's records indicated that the most recent fall intervention documented in the CCP was dated nearly a year prior to the incident, and the fall prevention focus had not been updated since before the fall. The Director of Nursing confirmed during an interview that the CCP lacked new fall interventions after the recent fall and acknowledged that updates should have been made in accordance with facility policy.
Failure to Provide Timely Repositioning and Incontinence Care
Penalty
Summary
Facility staff failed to provide timely repositioning and incontinence care for a resident who was dependent on staff for activities of daily living. Multiple observations over several days showed the resident lying in bed in the same position, with no evidence of being repositioned or having incontinence care provided for extended periods, sometimes up to five hours. Staff interviews confirmed that the resident was not checked, changed, or repositioned during these intervals, despite facility policy and the resident's care plan requiring repositioning at least every two hours and peri care after each incontinence episode. The resident in question had a history of cerebral infarction, dementia, mood disturbance, and anxiety, and was assessed as severely cognitively impaired and fully dependent for ADLs. The resident also had a pressure ulcer related to immobility and was at risk for further skin breakdown, as indicated by a Braden Scale score of 13 and frequent skin moisture. Observations documented the resident wearing heavily saturated briefs with foul odor, and staff acknowledged that the care provided did not meet the required frequency. The Director of Nursing confirmed the expectation for two-hourly checks and repositioning, and that refusals of care should be documented, but also stated there was no facility wound care policy.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency was identified when staff failed to follow proper infection prevention and control protocols during wound care for a resident. Specifically, an LPN did not don a gown prior to providing wound treatment, despite facility policy requiring the use of gowns and gloves for high-contact care activities such as wound care under Enhanced Barrier Precautions. The LPN also failed to change gloves and perform hand hygiene at appropriate times during the procedure, including after cleaning stool from the resident's buttocks and peri area, and before handling clean dressings and briefs. The resident involved had significant medical complexities, including Type 2 Diabetes Mellitus, hypothyroidism, bilateral above-knee amputations, mild cognitive impairment, peripheral vascular disease, and was dependent on staff for all care. The resident had a stage 2 pressure ulcer on the left buttock, which was acquired in the facility, and was at risk for further skin breakdown. The care plan required regular turning and repositioning, as well as adherence to wound care protocols to prevent infection and promote healing. During the observed wound care, the LPN removed a soiled brief and dressing, exposed the wound to a dirty brief, and used the same gloves for multiple tasks, including wound cleaning, dressing application, and peri care, without changing gloves or performing hand hygiene between steps. Both the LPN providing care and another LPN present confirmed in interviews that proper gown use and hand hygiene protocols were not followed, and that the wound should not have been exposed until after peri care and cleaning were completed.
Failure to Ensure 8-Hour Daily RN Coverage
Penalty
Summary
The facility failed to ensure sufficient staffing related to 8-hour daily RN coverage, which had the potential to affect all residents who reside in the facility. A record review of the staffing schedules for 5/1/24 through 5/20/24 revealed no 8-hour RN coverage on 5/12/24 and 5/16/24, and only 4 hours of RN coverage on 5/12/24. An interview with the facility Administrator on 05/23/24 confirmed that after pulling timecards, it was found that the facility did not have RN coverage on 5/6/24 and 5/12/24, and only 4 hours of RN coverage on 5/11/24. A record review of the Facility Assessment Tool dated 6/5/23 revealed that federal law requires nursing homes to have sufficient staff to meet the needs of residents, including the use of a registered nurse for at least 8 consecutive hours a day, 7 days a week.
Failure to Ensure Mandatory Continuing Education for Nursing Assistants
Penalty
Summary
The facility failed to ensure that five nursing assistants (NAs) completed the mandatory 12 hours of continuing education annually. A record review revealed that NA-K completed 6.7 hours, NA-L completed 0.50 hours, NA-M completed 5.05 hours, NA-N completed 0.50 hours, and NA-O completed 1.75 hours of continuing education in the last 12 months. This deficiency was confirmed by the facility Administrator during an interview, who acknowledged that the NAs had not met the required education hours despite being employed for more than one year. Additionally, an interview with NA-N revealed that the NA was unaware of the requirement for 12 hours of continuing education annually. The facility's Facility Assessment Tool, dated 6/5/23, outlined the necessity for NAs to complete specific training, including abuse prevention, dementia care, and at least 12 hours of continuing education per year. The failure to meet these training requirements had the potential to affect all residents in the facility, which had a census of 52 at the time of the report.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to ensure that Resident 47's wound care was completed as ordered by the provider. Resident 47, who was moderately cognitively impaired and had multiple medical diagnoses including Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, bone cancer, and lung disorders, was observed to have fluid-filled blisters on both lower extremities. The physician's orders specified the use of Betadine Paint on the blistered areas, followed by covering with Telfa and ABD dressings twice daily, and applying Triple Antibiotic Ointment to any ulcerated areas after Betadine application. However, during an observation, an LPN applied Povidone-Iodine swab stick only to the front of the resident's lower legs and did not paint the blistered areas on the sides as required by the physician's orders. In an interview, the LPN confirmed that they had misread the order and thought it was only necessary to paint the open area, not the blisters. As a result, the blisters on Resident 47's lower extremities were not treated with Betadine as prescribed. This failure to follow the physician's orders for wound care represents a deficiency in the facility's care practices for Resident 47.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure all infection control measures were followed during wound care for one resident, proper cleaning of a nebulizer kit and mask for another resident, and hand hygiene between glove changes during catheter care for a third resident. Specifically, an LPN did not perform hand hygiene between glove changes and used a dressing pad that had fallen on the carpeted floor during wound care for a resident with multiple medical conditions including Type 2 Diabetes Mellitus and bone cancer. The resident's care plan did not reflect the presence of wounds, and the LPN confirmed the errors in hand hygiene and the use of the contaminated dressing pad during an interview. Another resident, who was cognitively aware and had a history of COPD and lung cancer, did not have their nebulizer kit and mask cleaned after each use as required by the facility's policy. Observations revealed residual fluid and facial oils on the nebulizer kit and mask on multiple occasions, and the resident confirmed that staff did not clean the equipment after each treatment. An LPN also confirmed that the nebulizer kit should have been rinsed after each use but was not. Additionally, a nurse aide did not perform hand hygiene between glove changes while providing catheter care for a resident with acute congestive heart failure. The nurse aide confirmed the lapse in hand hygiene during an interview, and the facility's Director of Nursing also confirmed that hand hygiene should have been performed between glove changes. The facility's catheter care policy clearly outlined the steps for hand hygiene, which were not followed in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Falls City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Falls City Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Apostolic Christian Home | 15.7 mi | ★★★★★ | 0 | 0 |
| Maple Heights Nursing & Rehabilitative Center | 15.9 mi | ★★★★★ | 1 | 0 |
| Sabetha Manor | 16 mi | ★★★★★ | 7 | 0 |
| Colonial Acres Of Humboldt | 19 mi | ★★★★★ | 31 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.