Valley View Rehabilitation and Healthcare Ctr

Inspectors wrote4. On 4/21/25 at 10:00 AM, the surveyor observed Resident #3 in the facility activity room. The resident was seated in a chair with their walker next to them. The resident was dressed and groomed, and the surveyor observed no oxygen being used by the resident. On 04/21/25 at 11:00 AM, the surveyor inspected the resident's room and found no oxygen concentrator. On 4/21/25 at 11:20 AM, the reviewed the hybrid medical chart for Resident #3, which revealed the following: A review of the Resident #3's AR documented that the resident was admitted to the facility with diagnoses that included but were not limited to: anemia (low levels of healthy red blood cells), major depressive disorder (persistent depressed mood), anxiety disorder (feelings excessive fear or worry) and Alzheimer's disease (a progressive, degenerative brain disorder that causes memory loss). [...]

Inspectors wrote3. On 4/21/25 at 10:00 AM, the surveyor observed Resident #3 in the facility activity room. The resident was seated in a chair with their walker next to them. The resident was alert and showed no signs of behaviors. The resident was participating in activities with other residents. On 4/21/25 at 11:20 AM, the surveyor reviewed the hybrid (paper and electronic) medical chart for Resident #3 which revealed the following: A review of the Resident #3's admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: anemia, major depressive disorder, anxiety disorder and Alzheimer's disease. A review of the Annual MDS dated [DATE], revealed under Section C, a BIMS score of 5 out of 15 which indicated that the resident had severe cognitive impairment. [...]

Inspectors wroteBased on interview and review of the Nurse Staffing Report it was determined that the facility failed to ensure that a required Registered Nurse (RN) was present at the facility 7 days a week for at least 8 consecutive hours a day for 5 of 14 days reviewed. This deficient practice was evidenced by the following: Per the Interpretive Guidance §483.35(b) Facilities are responsible for ensuring they have an RN providing services at least 8 consecutive hours a day, 7 days a week. However, per Facility Assessment requirements at F838, §483.70(e), facilities are expected to identify when they may require the services of an RN for more than 8 hours a day based on the acuity level of the resident population. If it is determined the services of an RN are required for more than 8 hours a day. Facilities may choose to have differing tours of duty (e.g. [...]

Inspectors wroteRepeat Deficiency Based on observations, interview, review of facility job descriptions, it was determined that the facility failed to employ either a full time Registered Dietitian (RD) or a Dietary Manager (DM) that meets the qualifications to function as a director of food and nutrition services. This deficient practice was evidenced as follow: On 4/21/25 at 9:15 AM, the surveyor interviewed the Food Service Director (FSD #1), who is the FSD from another facility, but is covering for the facility FSD #2 today. FSD #1 revealed they work in a regional FSD capacity but does not come to the facility often. Per FSD #1, FSD #2 does not have any current dietary certifications, ServSafe, Certified Dietary Manager (CDM), and/or Certified Food Protection Professional (CFPP). FSD #1 further stated they would expect a FSD to have one or more of those certifications. [...]

Inspectors wroteBased on interview, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for 4 of 4 residents (Resident # 1, # 6, #15, and #16), during the 4/22/25 Resident Council group meeting and evidenced by the following: On 4/22/25 at 10:27 AM, the surveyor conducted the resident council meeting with four resident (Resident # 1, # 6, #15, and #16), who were alert and oriented, and selected by the facility to attend the group meeting. All four residents stated that they were not offered or received snacks in the evening. [...]

Inspectors wroteRepeat deficency 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 to prevent food borne illness. On 04/21/25 at 09:15 AM, the surveyor in the presence of the Food Service Director (FSD#1), observed the following during the kitchen tour: 1. The clipboard on wall contained the weekly food temperature log, the surveyor observed that no temperatures had been taken for dinner from 4/14/25 through 4/17/25 and 4/19/25. FSD#1 acknowledged the missing temperatures and stated they should have been recorded. 2. On the bread shelf, the surveyor observed a 28 ounce (oz) whole wheat bread with an open date of 4/8/25, without a use by date. Also observed was an open bag of flour tortilla without an open or use by date. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that there was a Licensed Nursing Home Administrator (LNHA) who was physically present and actively involved by providing daily oversight to ensure all policies and procedures were implemented. The evidence was as follows: On 4/21/25 at 9:30 AM, during entrance conference the surveyor met with the facility administrative team that included the Director of Nursing (DON) and the Regional Licensed Nursing Home Administrator (RLNHA). The TC was informed by the facility that the facility LNHA was not at the facility because of a religious holiday. Throughout the survey that lasted from 04/21/25 through 04/24/25, the LNHA was not observed in the building. [...]

Inspectors wroteBased on interview and review of pertinent facility provided documents, it was determined that the facility failed to ensure the facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies was reviewed and updated, as necessary, and at least annually. This deficient practice was evidenced by the following: On 04/21/25 at 09:30 AM, during the entrance conference held with the facility administration, the surveyor requested a copy of the Facility Assessment (FA). On 4/24/25 at 10: 30 AM, the surveyor was reviewing the FA that was provided by Regional Licensed Nursing Home Administrator (RLNHA). The FA was not signed and had a date of 4/25/25 and they were no evidence that the FA was conducted or reviewed prior to the surveyor team entering the building. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to assure the Licensed Nursing Home Administrator (LNHA) attended the quarterly Quality Assurance (QA) meetings. This was identified for 5 of the 5 QA meetings reviewed. This deficient practice was evidenced by the following: On 4/24/25 at 9:16 AM, the Director of Nursing (DON) provided the surveyor with the sign-in sheets for the last five QA meetings and showed the following: on 4/10/2024, 7/17/2024, 10/9/2024, 1/20/2025, and 4/2025 the LNHA failed to attend the QA meeting. On 4/24/25 at 9:45 AM, the DON provided the surveyor with the facility Quality Assurance & Performance Improvement (QAPI) Plan. Under the section titled, Governance and Leadership - Responsibility, the QAPI Committee meets at least quarterly and is composed of the following individuals: [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to a) provide appropriate care and services of urinary catheter care to prevent urinary tract infections, b) performed hand hygiene after urinary catheter care, c) no Transmission-Based Precautions (TBP) or Enhanced Barrier Precautions (EBP) signage outside the resident's door, and d) no Personal Protective Equipment (PPE) accessible observed with 1 of 2 residents reviewed for infection control practices (Resident #4). This deficient practice was evidenced by the following: On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake and sitting in bed with an indwelling urinary catheter inside the privacy bag (a tube placed inside the bladder to facilitate urine flow) lying on top of the bed. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the State of New Jersey inspection results were readily accessible for residents who resided in the facility. This deficient practice was identified for 4 of 4 residents (Resident #1, #6 #15, and #16) during the 4/22/25 Resident Council group meeting and evidenced by the following: On 4/21/25 at 9:00 AM, the surveyor observed that the State Survey results were located near the front entrance on the first floor. On 4/22/25 at 10:27 AM, the surveyor conducted the resident council meeting with four resident who (Resident #1, #6 #15, and #16) were alert and oriented, and selected by the facility to attend the group meeting. All four residents stated that they were not aware of the existence or location of the State Survey results. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 2 (two) of 8 residents (Resident #5 and #15) This deficient practice was evidenced by the following: The MDS is a comprehensive tool, federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. [...]

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), in accordance with federal guidelines for 2 of 8 residents (Residents #4 and #15) reviewed for accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake sitting in bed with oxygen (O2) at 2 lpm (liters per minute) via nasal cannula (N/C, a medical device that provides supplemental O2 therapy, the device has two prongs and sits below the nose. The two prongs deliver O2 directly into nostrils) connected to a portable oxygen concentrator (a device that supply an O2). Resident #4 stated that they also used oxygen at night and during activities at home. [...]

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) that included anticoagulant, antidepressant, and oxygen use. This deficient practice was identified for 3 of 8 residents (Resident #4, #5, and #15) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: 1. On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake sitting in bed on oxygen (O2) at 2 lpm (liters per minute) via nasal cannula (N/C, a medical device that provides supplemental O2 therapy, the device that has two prongs and sits below the nose. The two prongs deliver O2 directly into nostrils) connected to a portable oxygen concentrator (a device that supply an O2). [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) follow a physician's order, and b) place signage of oxygen (O2) therapy use according to standards of clinical practice and facility policy and procedure for 2 (two) of 2 residents, (Resident #4 and #15) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake sitting in bed on oxygen (O2 at 2 liters per minute (lpm) via nasal cannula (N/C), a medical device that provides supplemental O2 therapy, the device has two prongs and sits below the nose. The two prongs deliver O2 directly into nostrils) connected to a portable oxygen concentrator (a device that supply an O2). [...]

Inspectors wroteRepeat Deficiency 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 3 (three) of 5 (five) residents (Resident #1, Resident #10, and Resident #18) 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 one (1) of two (2) medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 11:38 AM, the surveyor inspected the high-side medication cart in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened Advair 250/50 inhaler with an opened date of [DATE] that was expired. At that time, the surveyor reviewed the manufacturer information on the inhaler in the presence of LPN#1. LPN#1 acknowledge that once opened the inhaler have an expiration date of 30-days. LPN#1 stated that the Advair inhaler was opened over 30-days ago and should have been removed from the medication cart. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. [...]

Inspectors wroteRepeat deficiency Based on interview and record review it was determined that the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for one of three PBJ Report submissions reviewed, (Fiscal Year Quarter 1 2025, October 1 - December 31) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area that the facility failed to submit data for the third fiscal year quarter to CMS. The dates of the first quarter 2025 included October 1, 2024, through December 31, 2024. On 04/22/25 at 10:00 AM, the surveyor interviewed the Staffing Coordinator (SC) who stated she was responsible for the nursing staff scheduling as well as reporting staffing daily to the Department of Health (DOH) website. [...]

Inspectors wroteBased on observations, interview, review of the facility assessment tool and facility job descriptions, it was determined that the facility failed to employ either a full time Registered Dietitian (RD) or a Dietary Manager (DM) that meets the qualifications to function as a director of food and nutrition services. This deficient practice was evidenced as follow: Refer to F812 F and E0015 F. On 11/15/2023 at 10:25 AM, the surveyor interviewed the Food Service Director (FSD) in the presence of a second surveyor. He stated that he had a Servsafe certification and started the position on 11/6/23. On 11/16/23 at 10:46 AM, the surveyor interviewed the FSD Consultant (FSDC) in the presence of the survey team. She stated that her credentials were Certified Dietary Manager (CDM), Certified Food Protection Professional (CFPP), and Servsafe certified . [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) store foods in a sanitary manner, b.) ensure the kitchen environment and equipment was maintained in a clean and sanitary manner, and c.) handle dishware in a manner to prevent cross contamination, to limit potential bacteria growth and potential food borne illness. The deficient practice was evidenced by the following: On 11/15/2023 at 10:25 AM through 12:28 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD) in presence of a second surveyor. At 10:26 AM, the surveyor observed a dish machine temperature log which was filled out for the entire day (afternoon and dinner time). The [NAME] stated, it was a mistake, usually I check the temperatures and then log them in. At 10:27 AM, the surveyors continued the tour with FSD. [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for one of three PBJ Report submissions reviewed, (Fiscal Year Quarter 3 2023, April 1 - June 30) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area that the facility failed to submit data for the third fiscal year quarter to CMS. The dates of the third quarter included April 1, 2023, through June 30, 2023. On 11/20/23 at 12:09 PM, the surveyor interviewed the Administrative Assistant (AA) in presence of a second surveyor. She stated, she was responsible for the nursing staff scheduling as well as reporting staffing daily to the Department of Health (DOH) website. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise a comprehensive care plan post fall for a resident who fell and sustained a left radial fracture. This deficient practice was identified for 1 of 1 resident (Resident #7) reviewed for falls. This deficient practice was evidenced by the following: On 11/16/23 at 11:44 AM, the surveyor observed the resident in his/her room seated in a chair combing his/her hair. The resident was able to tell the surveyor that he/she had a fall sometime in September in the bathroom and broke his/her wrist. The resident stated, I slipped and fell and showed the surveyor a yellow bracelet on his/her wrist which indicated fall risk. The surveyor reviewed the medical record for Resident #7. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to clarify a Physician's Order (PO) for oxygen administration in accordance with professional standards of practice for 1 of 1 resident reviewed for respiratory care (Resident #70). The deficient practice was evidenced by the following: On 11/15/23 at 11:41 AM, the surveyor observed Resident #70 in the facility activity room. Resident #70 was seated in a wheelchair and was participating in activities. The resident was receiving oxygen via nasal cannula. The oxygen concentrator was set at three liters per minute (LPM). On 11/16/23 at 11:10 AM, the surveyor observed Resident #70 in bed receiving oxygen via a nasal cannula. The oxygen concentrator was set at three LPM. The surveyor reviewed the medical record of Resident #70. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to physician orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 6 (six) residents (Resident #9) 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, record review, and review of pertinent facility documentation, it was determined that the facility staff failed to follow appropriate infection control practices for appropriately performing hand hygiene and sanitizing a blood pressure cuff between 2 of 2 residents observed during the medication pass, (Resident#5 and Resident #10). These deficient practices were evidenced by the following: On 11/17/23 at 8:35 AM, during the medication pass, the surveyor observed the Licensed Practical Nurse (LPN) obtaining Resident #10's vital signs. The LPN brought the electronic blood pressure cuff into the resident's room and took the resident's blood pressure. The LPN then returned to the medication cart which was in the hall. The surveyor observed the LPN placing the electronic blood pressure cuff on the medication cart. [...]

Inspectors wroteBased on observation, interview, and record review, it has been determined that the facility failed to consistently maintain professional standards of nursing practice regarding a) obtaining a physician's order for hemodialysis (HD) for 1 of 1 resident, Resident #5, reviewed for dialysis and b) documenting on the Electronic Treatment Administration Record (ETAR) for 1 of 10 residents, Resident #13, reviewed. The deficient practice is 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 maintain the necessary respiratory care and services. This deficient practice was identified for 2 of 2 residents (Resident #13 and Resident # 18) reviewed for respiratory care and was evidenced by the following: 1. On 07/27/21 at 9:53 AM, the surveyor saw Resident #13's nasal cannula placed on the bed beside the resident. The surveyor asked if the resident needed to have the oxygen on. Resident #13 stated that he/she should wear it and put it the nasal cannula on. The oxygen was running at 3 liters per minute (lpm). The surveyor reviewed Resident #13's Electronic Medical Record which indicated the following: According to the admission Record, the resident was admitted with diagnoses that included Heart Failure and Chronic Obstructive Pulmonary Disease. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to label and store multi dose vials in accordance with manufacturer specifications. This was found in 1 of 2 medication carts and 1 of 1 medication refrigerator. The deficient practice was evidenced by the following: On [DATE] at 10:27 AM the surveyor inspected the Long Term Care medication cart with the Licensed Practical Nurse (LPN). Inside of the medication cart there was a vial of Humalog insulin that was open and undated. There was a container that held the insulin vial. The container was dated [DATE]. The LPN confirmed the vial was not dated and that it should have been. There was also a vial of Lantus insulin that was open. The label attached to the vial read house stock. The vial had an open date written on it of [DATE]. The vial had been opened 56 days prior. [...]