Falls Village Skilled Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Falls Village Skilled Nursing & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 20, 2023

  Based on observation, staff and family interview, record review and review of the facility policy Pressure Ulcer Prevention and Assessment the facility failed to ensure Resident #330 was turned and repositioned at least every two hours to relieve pressure on his buttocks, failed to maintain an intact, ordered dressing in place to his sacrum and failed to ensure the setting on his low air loss (LAL) mattress was adjusted to the proper setting demonstrating a lack of care and services to prevent the development of a deep tissue pressure injury (persistent non-blanchable deep red, maroon or purple discoloration intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue). […]

• No harm, potential for more than minimal, widespreadF812Aug 7, 2026

  Based on observation, interview, and facility policy review, the facility failed to maintain a clean and sanitary kitchen area and maintain kitchen equipment in good working order. This had the potential to affect all residents receiving meals from the kitchen. The facility identified four residents (#1, #17, #78, and #98) as on a nothing by mouth (NPO) diet who did not receive food from the facility's kitchen. The facility census was 87.Findings include: Observation on 08/03/26 at 8:30 A.M. revealed the walk-in freezer had significant ice buildup on two boxes of nutritional supplement drinks. The ice buildup was below the freezer condenser unit. The main kitchen stove had dried drips and food debris on the front and sides. The floor surrounding the kitchen stove also had notable debris. […]

• No harm, potential for more than minimal, patternF656Aug 7, 2026

  Based on resident record review, resident interview, staff interviews, and facility policy review, the facility failed to implement resident care plans. This affected three residents (Resident #5, #15, #93) of four residents reviewed for care planning. The facility census was 87. 1. Review of the medical record for Resident #93 revealed she was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement, other specified disorders of synovium, left knee and chronic pain syndrome. Review of the facility dental summary treatment list dated 02/11/26 through 06/17/26 revealed Resident #93 was not listed. […]

• No harm, potential for more than minimal, patternF835May 11, 2023

  Based on observation, record review, review of Centers for Medicare and Medicaid Services (CMS) guidance and interview, the facility failed to ensure it was administered in a manner which enabled it to use its resources effectively and efficiently when they did not terminate the use of a temporarily certified Health Care Isolation Center (HCIC) area per CMS waiver guidelines as required. This affected 11 residents (#13, #52, #54, #55, #56, #57, #58, #59, #60, #61 and #64) of 11 residents residing in HCIC rooms. The facility census was 64. Findings include: Review of a facility application and survey history, revealed on 02/01/21, the facility was approved to operate as a HCIC with an In-House Surge Facility. The location of the HCIC was the first floor, Rooms 111 through 134. […]

• No harm, potential for more than minimal, patternF880Mar 20, 2023

  Based on observation, interview, record review, and policy review the facility failed to ensure proper cleansing of a multi-resident use glucometer after obtaining blood sugar for Resident #53 and returning it to the medication cart on the Birchwood unit. This affected one resident (#53) of five residents reviewed for medication administration and had the potential to affect nine residents (#5, #16, #21, #25, #27, #37, #39, #46 and #53) who required blood sugar testing on the Birchwood unit. The facility census was 80. Findings include: Review of Resident #53's medical record revealed he was admitted on [DATE] with diagnoses including type two diabetes, adjustment disorder with anxiety, and muscle weakness. […]