Fallsview Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint: 423561Repeat DeficiencyBased on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently provided for 5 of 6 residents (Resident #47, #68, #75, #78, and #106) reviewed for dietary preferences during meal observations. This deficient practice was evidenced as follows:1. On 3/15/26 at 9:20 AM, the surveyor observed Resident #47 in their room, sitting in a wheelchair (WC) eating breakfast. Resident #47 stated they were missing items from their tray. Surveyor observed Resident #47's breakfast tray ticket and tray. Resident #47 was missing a biscuit, one packet (pkt) of pepper and one pkt of ketchup. On 3/16/26 at 1:05 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #47.The admission Record (AR) (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to protein calorie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently implemented and correct diet consistency was followed for 3 of 5 residents (Resident #8, #19, and #51) reviewed for dietary preferences. This deficient practice was evidenced as follows: 1. On 9/26/24 at 08:35 AM, the surveyor observed Resident #8 in their room, awake in bed. During the interview, Resident #8 stated their meal trays are usually missing items and/or have incorrect items. Resident #8's breakfast tray arrived during the interview. Resident #8's breakfast ticket stated the resident was on a regular diet with a ground consistency (ground consistency are food that should be soft, moist, and cohesive in texture. Meats should be finely chopped, and vegetables should mash easily with a fork.) The surveyor observed Resident #8's tray were missing a 4 ounce (oz) pureed fruit cup and a 4 oz apple/cran-orange juice as indicated in their meal ticket. The surveyor further observed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner that would prevent food borne illnesses. This deficient practice was observed and evidenced by the following: On 9/25/24 at 09:41 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. The juice dispensing machine was observed with 3 of 6 juice plastic tubes that lead from the juice concentrate to the juice dispenser, with a sticky substance covering the tubes. The FSD stated the tubing should always be clean and free of any debris. 2. In walk-in refrigerator #1, the surveyor observed the fans, fan grates and panels with a dark colored dust like debris. 3. In the walk-in freezer, the surveyor observed large ice and frost build up on the fans, walls, and ceiling. The FSD could provide an information why the frost build up occurred. On 9/26/24 the Licensed Nursing Home Administrator (LNHA) provided the surveyor with two undated facility policies, titled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) for one (1) of 18 residents (Resident #75) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: On 09/25/24, at 10:20 AM, the surveyor observed Resident #75 in their room seated in bed wearing a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) (NC) connected to an oxygen (O2) concentrator at three (3) lpm which reflected on the O2 regulator. On 09/26/24 at 10:19 AM, the surveyor reviewed Resident #75's electronic medical record, which revealed the following information: The resident's admission Record (an admission summary) revealed that Resident #75 was admitted with diagnoses that included but were not limited to Respiratory failure unspecified by Hypoxia (lack of oxygen). The Quarterly Minimum Data Set (Q/MDS), dated [DATE], indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to administer oxygen therapy according to the physician's order for 2 of 2 residents (Resident #30 and #75) reviewed for Oxygen use. This deficient practice was evidenced by the following: 1. On 09/25/24 at 11:35 AM and on 09/26/24 at 11:30 AM, the surveyor observed on both days that Resident #30 was lying in bed, wearing a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) (NC) connected to an oxygen (O2) concentrator at two (2) liters per minute (lpm) on the regulator. On 09/25/24 at 12:01 PM, the surveyor reviewed Resident #30's electronic medical record, which revealed the following information: The resident's admission Record (an admission summary) (AR) documented that Resident #30 was admitted with diagnoses that included but were not limited to unspecified Dementia (impairment of memory). The Annual Minimum Data Set (A/MDS), an assessment tool used to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 4 (four) residents (Resident #61) observed during the medication observation pass. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store, and dispose of medications in two (2) of four (4) medication carts inspected. This deficient practice was evidenced by the following: On 10/1/24 at 10:15 AM, the surveyor inspected the first-floor medication cart #2 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened vial of Lantus insulin with an opened date of 8/24/24 and was expired. At that time, the surveyor interviewed LPN#1 who acknowledged that Lantus Insulin vial which was opened on 8/24/24 and was expired. She stated to the surveyor that Lantus insulin once opened had a 28-day expiration date. On 10/1/24 at 10:25 AM, the surveyor inspected the 1st floor medication cart #1 in the presence of LPN#2. The surveyor observed an unopened bottle of Xalatan eye drops (medication for pressure in the eye) that was not dated and was stored in the medication cart and an opened vial of Lantus insulin that contained no opened date. At that time, the surveyor interviewed LPN#2 who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ00164623 Based on interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure a) medication was accurately received, administered, and reconciled against the physician order prior to administration which contributed to a repeated administration of an incorrect dose to and proper disposal of Clonazepam (Klonopin; a hazardous, controlled substance/narcotic medication (med) to prevent and treat anxiety disorder), for Resident #390, b) accurate signing for a medication in the electronic medication administration record (eMAR), accurate accounting, dispensing, and administration of a controlled substance med, and med was administered according to physician orders and acceptable standards of practice, for Resident #78 and #47. This deficient practice was identified for three (3) of (3) residents (Resident #390, Resident #78, and Resident #47) reviewed for Clonazepam. This deficient practice was evidenced by the following: Reference: New…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication by following the pharmacy consultant recommendations for 1 (one) of 6 (six) residents reviewed for unnecessary medications (Resident #31). The deficient practice was evidenced by the following: On 7/24/23 at 11:06 AM, the surveyor observed Resident #31 lying in a low to the ground bed. The surveyor reviewed Resident #31's electronic medical record which revealed the following. A review of Resident #31's admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), anemia (problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and schizophrenia (A disorder that affects a person's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure a physician's order was followed and perform hand hygiene appropriately during a wound treatment observation for 1 (one) of 1 (one) resident, (Resident #31) reviewed for pressure ulcer. The deficient practice was evidenced by the following: On 7/24/23 at 11:06 AM, the surveyor observed Resident #31 lying in a low to the ground bed. The surveyor observed a wound vacuum machine on the bedside table and there was a tubing that was connected to Resident #31. The surveyor reviewed Resident #31's electronic medical record which revealed the following: The admission Record (or face sheet; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), anemia (problem of not having enough healthy red blood cells or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY NJ00164623 Based on interviews, record review, and review of facility provided documents, it was determined that the facility failed to ensure that two (2) Licensed Practical Nurses (LPN #1 and #2) and one (1) Registered Nurse (RN) had Medication Pass Observation (MPO) competencies to provide nursing care for residents' needs. The deficient practice was evidenced by the following: A review of the facility provided Medication Error Incident Report ([NAME]) for 5/27/23 date of error showed that it was the RN who had a medication error of Klonopin (anti-anxiety medication) for Resident #390 and was given a written warning. In addition, the 5/29/23 and 5/30/23 dates of error in the [NAME] showed that it was LPN#1 who had a medication error of Klonopin for Resident #390 and was given a written warning. Further review of the 5/27/23, 5/29/23, and 5/30/23 dates of medication errors, included in the [NAME] revealed that on the explanation/reason medication error was made by the RN and LPN#1: Resident was previously…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint # NJ00164623 Based on observation, interview, record review, and review of the facility provided documents, it was determined that the facility failed to identify medication irregularity during the monthly MRR (Medication Record Review) of the CP (Consultant Pharmacist) for two (2) of three (3) residents, (Resident #390 and Resident #78) reviewed for Clonazepam (or Klonopin; antianxiety medication). This deficient practice was evidenced by the following: A review of the manufacturer's specifications for Klonopin included the following: Geriatric Use, Clinical studies of Klonopin did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.