Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Falling Water Healthcare Center during CMS and state inspections, most recent first.
The facility did not consistently offer or hold care plan meetings for several residents, as confirmed by record reviews and interviews. Cognitively intact residents and their representatives were not invited to participate in care planning beyond initial meetings, and staff acknowledged the lack of a systematic process for scheduling these meetings, contrary to facility policy.
A resident with depression and quadriplegia did not receive a required $50 social security allowance for one month after a delay in the deposit of their check. The facility's system failed to recognize the need for a retroactive payment, resulting in the resident not receiving the allowance for that period, as confirmed by business office staff and record review.
Three residents were not provided with meals that accommodated their documented allergies, dietary restrictions, or preferences. One resident with an egg allergy received the wrong fruit preparation, another who required double portions was served a regular portion, and a third with a lactose allergy was served an entrée containing milk instead of the specified alternative. These errors were identified by dietary staff during meal service.
A resident with moderate cognitive impairment in a memory care unit sustained a second-degree burn on her hand after a CNA heated noodle soup in a microwave and handed it to her, contrary to facility policy. The resident placed the soup on her walker, lost her balance, and fell, spilling the hot soup onto her hand. The incident revealed a failure to adhere to the facility's policy on reheating food, which requires dietary services to handle such tasks.
A facility failed to implement effective behavioral interventions for a resident with dementia, who had a history of inappropriate sexual behaviors. Despite initial interventions, the care plan was not updated promptly after incidents, leading to repeated inappropriate behaviors. The facility's policies on managing psychiatric behaviors were not effectively applied, resulting in multiple incidents involving the resident.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, affecting all 108 residents. The deficiency was due to challenges in hiring RNs, leading to insufficient staffing on weekends across several months.
A facility failed to notify a resident's family of a change in condition and hospitalization. The resident, with multiple health issues, showed unusual behavior and was sent to the ER. Despite the facility's policy requiring prompt notification of significant changes, the family was not informed, as confirmed by an LPN/Unit Manager.
The facility failed to provide routine showers to two residents who were dependent on staff for activities of daily living (ADLs). Despite having intact cognition, both residents reported not receiving showers as scheduled, and an LPN confirmed that only one shower was documented for each resident in the past three months. The facility's policy on routine care, which includes bathing, was not followed.
A facility failed to follow infection control measures during medication administration. An LPN was observed handling levetiracetam tablets with bare hands before placing them in a medication cup for a resident with epilepsy and other conditions. This action was against the facility's policy, which prohibits touching medications with bare hands.
A resident requiring two-person assistance for ADLs fell and sustained a fractured left hip when only one staff member was present during personal care. The resident, with a history of conditions increasing fall risk, rolled off the bed while holding a grab bar. The use of an air mattress was noted as a potential factor in the fall.
The facility failed to maintain a medication error rate of less than five percent, resulting in a 12.00% error rate. Errors included administering a chewable aspirin instead of an enteric-coated tablet to a resident and giving expired Mucinex and an unspecified dose of iron to another resident. The errors were confirmed by the LPNs involved.
A resident with multiple diagnoses, including stroke and chronic kidney disease, experienced an incident during transport where they began to slide out of their wheelchair and complained of chest pain. The transporter called 911, and the resident was taken to the ER via EMS. The incident was not documented in the resident's medical record, contrary to the facility's clinical documentation standards.
Failure to Offer or Hold Care Plan Meetings for Residents
Penalty
Summary
The facility failed to ensure that residents were offered or included in care conference meetings as part of their person-centered care planning. Record reviews and interviews revealed that four residents, all of whom had quarterly Minimum Data Set (MDS) assessments completed and were either cognitively intact or had a representative, did not have documented care plan meetings beyond their initial or early admission meetings. For example, one resident was only invited to a single meeting after admission, which he missed, and had no further documented invitations. Another resident and his mother reported not receiving invitations to care plan meetings for an extended period, and the last documented meeting was several months prior. A third resident's family stated they were not contacted or invited to participate in care planning, and the last meeting on record was also several months old. The fourth resident, who was cognitively intact, reported not being involved in any care plan meetings during his year-long stay, with the last documented meeting occurring months before the review. Interviews with facility staff, including a licensed social worker and an LPN, confirmed that care plan meetings were not consistently offered or held for all residents as required. The social worker identified issues related to staffing changes and lack of a systematic approach to scheduling these meetings. The facility's own policy stated that residents and their representatives should be included in all aspects of care planning and be given opportunities to participate, but this was not followed in practice. The deficiency was identified during a complaint investigation and affected four out of four residents reviewed for participation in care planning.
Failure to Provide Resident Social Security Allowance Due to Missed Retroactive Payment
Penalty
Summary
The facility failed to ensure that a resident had access to his social security allowance as required. The resident, who was cognitively intact and had diagnoses including depression and quadriplegia, had his social security check for February recalled by Social Security and not deposited until April. As a result, the system did not recognize that the resident should have received his $50.00 allowance retroactively for February. The resident did not receive this allowance, even though subsequent months' allowances were properly allotted and withdrawn by the resident as documented by signed receipts. Interview with the Regional Business Office Manager confirmed that the oversight occurred because the system did not account for the late deposit of the February check, and the resident was not given his $50.00 allowance for that month. This deficiency was identified during a review of the resident's personal fund statements and was verified through interviews and record review.
Failure to Accommodate Dietary Allergies and Preferences During Meal Service
Penalty
Summary
The facility failed to provide food that accommodated resident allergies, dietary intolerances, and preferences for three residents. One resident with an egg allergy and a preference for ground fruit cocktail was initially served regular fruit cocktail instead of the required ground version, as indicated on her tray ticket. Another resident, who was supposed to receive double portions due to a physician order, was served only a regular portion of chicken piccata, contrary to the tray ticket instructions. Both discrepancies were identified by dietary staff during meal service. A third resident, with a documented lactose allergy and a physician order for a carbohydrate control renal diet, was served chicken piccata containing milk instead of the required baked chicken breast, as specified on her tray ticket. This error was also identified by dietary management staff before the meal was delivered. All three residents were noted to have either intact or moderately impaired cognition and were independent in eating. The deficiencies were observed through direct observation, interview, and record review, and were verified by dietary staff at the time of the incidents.
Resident Burn Incident Due to Hot Soup
Penalty
Summary
The facility failed to provide adequate care and services to prevent a second-degree burn on a resident's right hand. The incident occurred when the resident, who had moderate cognitive impairment and resided in a secured memory care unit, was handed a hot noodle soup by a CNA. The soup had been heated in a microwave by the CNA, who was aware of the facility policy against heating food for residents but had done so regularly for this resident. The resident placed the soup on her walker, and as she stepped back, she lost her balance, fell, and spilled the hot soup onto her hand, resulting in a burn. The resident's medical record indicated she was admitted with diagnoses including unspecified dementia, essential hypertension, and bipolar disorder. A hot liquid evaluation form revealed no severe cognitive impairment or other indicators that would suggest a high risk for accidents. However, the resident's quarterly MDS assessment showed moderate cognitive impairment. During the incident, the resident fell backward, hitting her head and elbow, and sustained a burn on her right hand. The burn was initially red and moist, with optimal granulation color and pain, and later developed into a second-degree burn with a blister. Interviews with staff revealed that the CNA had heated the soup for the resident despite knowing the policy against it. The LPN on duty was more concerned about potential injuries to the resident's head and elbow and did not initially notice the burn on the hand. The facility's policy stated that dietary services should handle reheating food, but in their absence, trained staff could do so, ensuring the food reached a safe temperature and was allowed to cool before serving. The incident highlighted a lapse in following these procedures, leading to the resident's injury.
Removal Plan
- LPN Unit Manager #825 completed a skin assessment on Resident #68 and noted redness to the right hand measuring one cm length by two cm width with no depth. The resident's skin was intact.
- LPN UM #825 completed interviews with unit staff. The staff reported Resident #68 lost her balance due to being distracted and talking to other residents.
- The Interim DON was notified of the incident by LPN UM #825.
- The Interim DON reviewed Resident #68's diet order. The order was for a regular/regular/regular diet with no devices.
- The Interim DON reviewed Resident #68's MDS and Care Plans and no diet modifications were noted.
- The Interim DON completed an audit by assessing all residents in house for potential for risk of injury due to hot food items/liquids. No abnormal findings were identified.
- LPN UM #825 educated all facility staff on Hot Liquids and initiated an in-service.
- NP #815 ordered an ice pack to Resident #68's right hand twice daily as tolerated, and the ice pack was added to the resident order list.
- Review of the Outside Food policy by the Administrator and DON revealed no changes were made.
- NP #815 assessed Resident #68. No swelling to the head was observed. Redness to the right hand was observed with intact skin. Neurological checks were within normal limits and range of motion was within normal limits. A verbal order for an ice pack was received and initiated.
- An interdisciplinary team meeting was held regarding the incident which included the Administrator, Interim DON, LPN UM #832, LPN UM #825, LPN MDS #861, Therapy #602, Licensed Social Worker #603.
- NP #815 followed up with Resident #68 and treatment orders were obtained and implemented.
- NP #815 ordered bacitracin ointment to the right hand twice daily.
- The Interim DON initiated ongoing monitoring audits three times a week for four weeks related to monitoring residents for risk for injury related to hot liquids/foods. The audits were being monitored for compliance by the DON in conjunction with the Administrator daily during the clinical meeting and weekly during the nursing risk meeting.
- LPN UM #825 completed Storage of Resident Food Hot policy in-service with focus on hot liquids/foods to all facility staff.
- Speech Therapy evaluation was completed by Speech Therapist #604 and an order received for ST services three times a week for four weeks for cognitive skills development.
- A skin evaluation was completed on Resident #68's right hand burn. The resident was added to wound care rounds with Wound NP #985 (routine). The burn to the right hand measured one cm length by two cm width with no depth and was red in color with no exudate and no pain.
- The physician orders were to continue the treatment of Bacitracin topically twice daily. The resident's right hand had an intact blister which was noted to the center of the burn.
- A wound assessment was completed with the facility wound nurse LPN UM #825 and Wound NP #985. The burn to the right hand measured at 1.5 cm length by one cm width with 0.1 cm depth. Dryness was noted to the periwound with scant serous exudate. The treatment orders was changed to Silverdene cream 1% twice daily and as needed.
- The treatment order for Resident #68 was changed to Silvadene twice daily and as needed by Wound NP #985.
Inadequate Behavioral Interventions for Resident with Dementia
Penalty
Summary
The facility failed to implement comprehensive, individualized, and effective behavioral health interventions for a resident diagnosed with dementia, who had a history of inappropriate sexual behaviors. The resident was admitted with diagnoses including vascular dementia, anxiety disorder, and depression. Despite having intact cognition upon admission, the resident was involved in multiple incidents of inappropriate sexual behavior with other residents, which were not adequately addressed by the facility's care plans. The resident's behavior care plans included interventions such as administering medications, speaking calmly, encouraging expression of feelings, and monitoring behavior episodes. However, these interventions were not updated or revised following an incident on September 29, where the resident was observed engaging in a sexual interaction with another resident. It was not until October 7 that an intervention to monitor for inappropriate sexual behaviors was added, indicating a delay in addressing the resident's behavioral issues. Further incidents occurred, including one on October 23, where the resident was found in bed with another resident, both undressed. Despite the implementation of behavior monitoring orders and a psychiatric assessment after the first incident, the facility did not provide one-to-one monitoring indefinitely, nor was this intervention included in the resident's plan of care. The facility's policies on providing resident-centered care and managing behaviors related to psychiatric diagnoses were not effectively implemented, leading to repeated incidents of inappropriate sexual behavior by the resident.
RN Coverage Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Staffing Data Report, which revealed multiple dates across three fiscal quarters where RN coverage was insufficient. The lack of RN coverage had the potential to affect all 108 residents residing in the facility. Interviews with the facility's administrator and payroll specialist confirmed the absence of RNs on specific dates, indicating a systemic issue in maintaining adequate staffing levels. The deficiency was attributed to challenges in hiring registered nurses, as noted by the administrator who began working at the facility in April 2024. The facility experienced RN shortages on weekends, particularly Saturdays and Sundays, across several months. This issue persisted despite efforts to address staffing concerns, highlighting a significant gap in compliance with regulatory requirements for RN coverage in the facility.
Failure to Notify Family of Resident's Hospitalization
Penalty
Summary
The facility failed to notify a resident's family of a change in condition and subsequent hospitalization, affecting one resident. The resident, diagnosed with multiple sclerosis, diabetes mellitus II, and depression, required staff assistance with all activities of daily living. On a specific date, the resident exhibited unusual behavior, repeating phrases and appearing lethargic, which was a significant change from her usual alert and oriented state. Despite these changes and the decision to send her to the emergency room for further evaluation, there was no documentation indicating that the resident's family was informed of the situation. The facility's policy on Notification of Change in Condition mandates prompt notification of significant changes to the attending practitioner and the resident's representative, with documentation of the notification, response, and interventions in the medical record. However, an interview with the LPN/Unit Manager confirmed that the family was not notified of the resident's change in status and hospitalization. This oversight was identified during an investigation under a specific complaint number, highlighting non-compliance with the facility's policy.
Failure to Provide Routine Showers to Dependent Residents
Penalty
Summary
The facility failed to ensure that dependent residents received routine showers, affecting two residents out of three reviewed for activities of daily living (ADLs). Resident #13, who has a history of traumatic brain injury, depression, anxiety disorder, and seizures, was found to have intact cognition but was dependent on staff for ADLs. Despite this, there was no documentation of Resident #13 refusing showers, and interviews revealed that the resident had to repeatedly ask for showers. A Licensed Practical Nurse (LPN) confirmed that only one shower was documented for Resident #13 in the past three months. Similarly, Resident #31, diagnosed with multiple sclerosis, major depressive disorder, and anxiety disorders, was also dependent on staff for all ADLs except eating. The resident reported not receiving showers as scheduled, and the same LPN confirmed that only one shower was documented for Resident #31 in the past three months. The facility's policy on routine care, which includes bathing, was not adhered to, as evidenced by the lack of documentation and resident reports.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control measures during medication administration, affecting one resident. The incident involved a Licensed Practical Nurse (LPN) who, while preparing to administer medication to a resident with a history of traumatic brain injury, epilepsy, and alcohol abuse, directly handled levetiracetam tablets with her bare hands. This action was observed during a morning medication round. The facility's policy on medication administration, dated April 16, 2024, explicitly states that medications should not be touched with bare hands when opening a liquid or dose pack. Despite this policy, the LPN admitted to handling the tablets with her hands because they were large, indicating a deviation from the established protocol.
Inadequate Assistance Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate assistance during personal care, resulting in a fall with major injury for a resident. The resident, who required two-person assistance for activities of daily living (ADLs), was being cared for by only one staff member at the time of the incident. This lack of sufficient assistance led to the resident rolling out of bed and sustaining a fractured left hip. The incident occurred when the resident was being changed and rolled off the side of the bed while holding onto a grab bar. The resident had a medical history that included anemia, orthostatic hypotension, chronic kidney disease, and other conditions that placed them at risk for falls. The care plan indicated the need for substantial to maximal assistance with ADLs, including two or more helpers for certain tasks. However, during the incident, only one staff member was present, which was insufficient to prevent the fall. The resident was on an air mattress, which was noted as a suspected root cause of the fall, as it may have contributed to the resident's instability. The staff member involved in the incident attempted to prevent the fall but was unable to reach the resident in time. The resident was found on the floor with multiple abrasions and bruising, and x-ray imaging later confirmed a possible fracture of the left hip. The facility's failure to adhere to the care plan's requirement for two-person assistance directly contributed to the resident's fall and subsequent injury.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a medication error rate of 12.00%. This was due to three observed medication errors out of 25 medication administration opportunities, affecting two residents. For Resident #9, who had diagnoses including dysphagia, hemiplegia, aphasia, anxiety disorder, and reflux disease, the error involved administering a chewable aspirin tablet instead of the prescribed enteric-coated, delayed-release tablet. The LPN confirmed the error during an interview. For Resident #42, who had diagnoses including bipolar disorder, depression, chronic obstructive pulmonary disease, and coronary artery disease, the errors included administering an expired Mucinex 600 mg tablet and an iron tablet without a specified dose. The LPN confirmed she did not check the expiration date and administered the iron tablet because it was the only one available. The Clinical Manager also confirmed that the iron order did not include a dose. The facility's policy on medication administration was reviewed and found to be noncompliant with providing resident-centered care.
Failure to Document Resident Incident During Transport
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record of a resident who experienced an incident during transport. The resident, who had diagnoses including cerebral infarction, stroke, and chronic kidney disease, was moderately cognitively impaired and dependent on staff assistance for transfers. On the day of the incident, the resident was returning from an eye appointment when they began to slide out of their wheelchair in the facility van, complained of chest pain, and felt weak and sick. The transporter called 911, and the resident was taken to the emergency room via EMS. However, the medical record did not include any documentation of this incident. Interviews with the transporter and the Director of Nursing confirmed the occurrence of the incident and the lack of documentation in the resident's medical record. The facility's policy on clinical documentation standards requires timely and accurate documentation of resident information, which was not followed in this case. This deficiency affected the accuracy and completeness of the resident's medical record, as the incident and subsequent hospital transport were not recorded.
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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 Strongsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altenheim | 1.4 mi | — | 4 | 0 |
| Strongsville Healthcare And Rehabilitation | 2.9 mi | — | 2 | 0 |
| Diplomat Healthcare | 3 mi | — | 8 | 0 |
| O'neill Healthcare Middleburg Heights | 3.3 mi | — | 7 | 0 |
| Hopkins Rehabilitation And Care Center | 3.4 mi | — | 0 | 0 |
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