Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe dementia, behavioral disturbance, depression, cognitive communication deficit, and bilateral glaucoma had head pain and later was found to have a C1 fracture after a fall. Staff did not document fall assessments, and an LPN initially denied the fall before later admitting the resident had been on the floor and was assisted back to a recliner without assessment, documentation, or reporting. The facility also failed to notify the physician and resident representative as required.
The facility did not ensure its chemical low-temp dish machine reached the required 120°F during wash and rinse cycles, with staff confirming the machine often failed to meet this standard until several loads had run. Additionally, spoiled vegetables from the facility's garden were found on the kitchen sink and not promptly disposed of, with staff acknowledging the lapse. These deficiencies had the potential to affect nearly all residents consuming food from the kitchen.
A resident with Parkinson's disease and dementia, who showed signs of dysphagia such as coughing and choking during meals and medication administration, did not receive ordered speech therapy (ST) services. Although an ST evaluation and treatment order was in place, there was no documentation of ST being provided after the resident's last discharge from therapy, and staff confirmed the absence of an ST on site.
Surveyors found that two residents with respiratory conditions had unclean and improperly maintained PAP devices and oxygen equipment. Observations included missing filters, dirty and worn tubing, masks with visible residue, and nasal cannulas resting on the floor. Staff interviews confirmed that cleaning and storage protocols were not followed, despite clear physician orders and facility policies.
Surveyors observed that medication carts containing residents' medications were left unlocked and unattended near the nurse's station on two separate occasions. The DON confirmed that the carts were not secured as required by facility policy, which mandates that medication carts be locked when unattended.
The facility inaccurately coded MDS assessments for four residents, leading to discrepancies in medication records and hospice status. Errors included incorrect documentation of GDR attempts and contraindications, as well as misclassification of medications such as anticoagulants and antiplatelets. Additionally, a resident's terminal status was not accurately reflected in the MDS.
A facility failed to develop a hospice care plan for a resident receiving hospice services. Despite a significant change MDS indicating the need for hospice care, the comprehensive care plan lacked any hospice-related details. The facility's policy requires care plans to be updated for significant changes, but this was not done. An MDS nurse confirmed the oversight.
Failure to Notify Physician and Report Resident Fall With Head Injury
Penalty
Summary
The facility failed to notify the resident’s physician of a change in condition, failed to report a fall that delayed the resident’s medical care, and failed to follow standards of practice after a head injury for one resident with severe dementia, behavioral disturbance, depression, cognitive communication deficit, and bilateral absolute glaucoma. The resident’s care plan included physician-ordered CT scanning, ice to a hematoma on the head, neurological checks, moving the recliner out of the room for increased supervision, and later use of Dycem in the recliner. Progress notes showed the resident complained of head pain and later was agitated with pain in the back of the head. The resident was transported to the hospital for a CT, and the hospital later reported that the resident had fallen at 2:00 AM and had a C1 fracture. The facility record also showed there were no assessments documented for the resident’s fall on the two days before the hospital notification. During the facility investigation, a therapist reported seeing the resident on the floor in the resident’s room and told a CNA, and the CNA stated that an LPN and the CNA assisted the resident off the floor and into the recliner. The LPN initially denied knowing about a fall, then later admitted the resident had been on the floor, that the resident was assisted up, and that the resident was not assessed, documented, or reported. The facility policy required a physical assessment after a fall and notification of the physician and resident’s representative, and the notification policy required prompt notification of the resident, physician, and family or responsible party for changes in condition.
Failure to Maintain Proper Dishwashing Temperatures and Safe Food Storage
Penalty
Summary
The facility failed to ensure that its chemical low-temperature dish machine consistently reached the required minimum temperature of 120 degrees Fahrenheit during both wash and rinse cycles, as observed during multiple uses by dietary staff and management. The dish machine was documented to reach only 88 to 112 degrees Fahrenheit during several cycles, and staff confirmed that it typically required running three to four loads before reaching the necessary temperature. The Dietary Manager and Regional Certified Dietary Manager both operated the dish machine without achieving the required temperatures, and the issue was corroborated by a representative from the contracted dish machine service company, who confirmed the minimum temperature requirements for proper sanitization. Additionally, the facility did not properly dispose of spoiled vegetables from its garden, as evidenced by the presence of a box containing a cucumber with a gray fuzzy coating and two soft tomatoes with brown holes and a gnat inside one of them, found on the 3-compartment sink in the kitchen. The Activities Director, acting as the Dietary Manager at the time, confirmed the spoiled produce was from the facility's garden and acknowledged it should not have been present in the kitchen. These deficiencies had the potential to affect 38 residents who consumed food prepared in the facility's kitchen.
Failure to Implement Speech Therapy Orders for Resident with Dysphagia
Penalty
Summary
Facility staff failed to implement physician-ordered speech therapy (ST) services for a resident with Parkinson's disease and dementia who exhibited signs of dysphagia, including coughing and choking during meals and when swallowing medications. The resident's Minimum Data Set (MDS) documented symptoms of a swallowing disorder, and the comprehensive care plan included monitoring for dysphagia but did not specify interventions for responding to symptoms. A provider order for ST evaluation and treatment was obtained and signed, but there was no documentation of ST services being provided after the resident's last discharge from ST in early 2024. Observations revealed the resident continued to experience coughing and choking episodes during meals and after taking medications. Staff interviews confirmed awareness of the resident's symptoms and that the facility had not had an ST on staff since December 2024, with some residents being sent offsite for therapy. The Director of Nursing confirmed that the resident had not received ST since 2024, despite the active order and ongoing symptoms.
Deficient Infection Control in Respiratory Equipment Care
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control program related to the care and maintenance of respiratory equipment for two residents. For one resident with orders for both oxygen therapy and a positive airway pressure (PAP) device, observations revealed that the PAP device was missing its required filter, the tubing was discolored, bent, and coated with visible residue, and the mask had not been cleaned. The resident's nasal cannula was repeatedly observed resting on the floor, and the oxygen concentrator's filters were covered in dense, gray, fuzzy sediment. Facility policies required regular cleaning and replacement of these items, but these procedures were not followed. Another resident, who had diagnoses including sleep apnea, emphysema, and COPD, was also found to have a PAP device mask with visible brown and black flecks on the inside surface during multiple observations. The mask was left on various unclean surfaces, such as a used clothing protector, a blanket, and a hat, rather than being properly cleaned and stored. The resident's nasal cannula was also observed lying on the floor. Staff interviews confirmed that the equipment should have been cleaned daily and stored appropriately, but these practices were not consistently implemented. Record reviews showed that both residents had physician orders and care plans specifying the need for daily cleaning of respiratory equipment and proper storage of tubing and masks. Despite these documented requirements, staff failed to ensure that the equipment was maintained in a clean and sanitary condition, and failed to keep tubing and cannulas off the floor, as confirmed by both nursing staff and the Director of Nursing during interviews.
Unattended and Unlocked Medication Carts
Penalty
Summary
The facility failed to secure all medications in a locked storage area and did not limit access to authorized personnel as required by policy and regulation. Observations on two separate occasions revealed that a medication cart containing residents' medications was left unlocked and unattended near the nurse's station. The Director of Nursing (DON) confirmed during interviews that the medication cart was indeed unlocked and acknowledged that it should have been locked. The facility's own Drug Storage Policy states that drugs and biologicals should not be left unsecured or unattended, and that medication carts must be kept locked when unattended. These findings were based on direct observation, interviews, and review of facility policy.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in their medical records. For Resident 9, the MDS was incorrectly coded regarding the use of antipsychotic medication and the status of a Gradual Dose Reduction (GDR). Although the physician had documented that a GDR was clinically contraindicated, the MDS did not reflect this accurately, marking 'No' instead of 'Yes' for the contraindication, and incorrectly indicating that a GDR had been attempted. Resident 11's MDS also contained errors, with the date of the last attempted GDR incorrectly recorded as 7/24/23 instead of the correct date, 11/17/24. Additionally, the MDS inaccurately indicated that a GDR was documented as clinically contraindicated, which was not the case. For Resident 19, the MDS inaccurately recorded the use of anticoagulant and diuretic medications, while failing to note the use of an antiplatelet medication, which was actually prescribed. Resident 34's MDS was similarly flawed, incorrectly indicating the use of an anticoagulant instead of an antiplatelet medication. Furthermore, despite being admitted to hospice care with a prognosis of less than six months, the MDS did not reflect this terminal status. These inaccuracies in the MDS assessments highlight significant documentation errors that could impact the residents' care plans and treatment outcomes.
Failure to Implement Hospice Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered comprehensive care plan for a resident who was receiving hospice services. The resident's Significant Change Minimum Data Set (MDS), completed on May 3, 2024, indicated that the resident was receiving hospice care. However, the comprehensive care plan, dated July 9, 2024, did not include any resident-centered care plan related to hospice services. The facility's Care Plan policy states that care plans should be modified between care plan conferences to meet the resident's current needs and should be updated for significant changes in the resident's condition. An interview with the MDS nurse on July 10, 2024, confirmed that there was no hospice care plan for the resident, and one should have been developed and implemented following the completion of the significant change MDS.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 63 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Maple Heights Nursing & Rehabilitative Center | 15 mi | ★★★★★ | 1 | 0 |
| Apostolic Christian Home | 15.9 mi | ★★★★★ | 0 | 0 |
| Sabetha Manor | 16.2 mi | ★★★★★ | 7 | 0 |
| Tiffany Heights | 19.7 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Falls City Nursing And Rehabilitation Center.
100% money-back within 48 hours.
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.