Fallsview Nursing and Rehabilitation Center

Inspectors wroteComplaint: 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for one (1) of 18 residents (Resident #71) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: On 09/25/24 at 11:05 AM, the surveyor observed Resident #71 seated in bed with the indwelling catheter (closed sterile system with a catheter and retention balloon that is inserted either through the urethra or suprapubically to allow for bladder drainage) inside a privacy bag, draining yellowish urine. The resident was able to respond to surveyor's inquiry. [...]

Inspectors wroteComplaint # NJ00164623 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident was free of significant medication errors regarding the administration of anti-anxiety medication in accordance with the physician's order to prevent an adverse outcome for Resident #390. The facility failed to ensure that nurses administered medication to Resident #390 in accordance with professional standards of nursing practice. [...]

Inspectors wroteComplaint # 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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; [...]

Inspectors wroteNJ00164623 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. [...]

Inspectors wroteComplaint # 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. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to transmit the Minimum Data Set (MDS) assessments in a timely manner. This deficient practice was identified for 1 (one) of 1 (one) residents, (Resident#7) reviewed timeliness of MDS transmission according to the RAI (Resident Assessment Instrument) Manual. The evidence was as follows: According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Guide Version 1.17.1, October 2019 which included that RAI OBRA (Omnibus Budget Reconciliation Act)-Required Assessment Summary: Discharge Assessment Return Not Anticipated and Discharge Return Anticipated transmission date no later than MDS completion date + 14 days calendar days. [...]