Deficiency Records for Falls Village Skilled Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Falls Village Skilled Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-14 | 2024-01-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-12-14 | 2024-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-14 | 2024-01-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-14 | 2024-01-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-14 | 2024-01-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-14 | 2024-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-14 | 2024-01-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-11 | 2023-05-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-20 | 2023-04-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-20 | 2023-04-08 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-20 | 2023-04-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-20 | 2023-04-08 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-20 | 2023-04-08 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-20 | 2023-04-08 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-15 | 2023-04-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-15 | 2023-04-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-15 | 2023-04-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-15 | 2023-04-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-15 | 2023-04-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-22 | 2022-08-16 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-01-04 | 2022-06-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-01-04 | 2022-02-12 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-01-04 | 2022-02-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-04 | 2022-02-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-01-04 | 2022-02-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-04 | 2022-02-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-04 | 2022-02-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-04 | 2022-02-12 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-01-04 | 2022-02-12 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-01-04 | 2022-02-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-18 | 2021-09-11 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2021-05-14 | 2021-05-29 | Y |
