Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fallsview Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
The facility failed to consistently implement dietary preferences and correct diet consistencies for three residents, leading to deficiencies in their care. A resident on a regular diet with ground consistency received incorrect items, while another resident frequently received meal trays missing requested items like cranberry juice. A third resident experienced missing items such as prune juice, ordered for constipation prevention. The facility's policy on tray accuracy was not followed, contributing to these deficiencies.
The facility failed to maintain proper kitchen sanitation practices, as observed by surveyors. Issues included sticky residue on juice dispenser tubes, dust-like debris on refrigerator fans, and ice buildup in the freezer. The facility's cleaning schedule was not up-to-date, and no further information was provided by the LNHA and DON.
A facility failed to develop and implement a comprehensive care plan for a resident using oxygen therapy and requiring restorative nursing exercises. The care plan did not reflect the physician's orders for oxygen administration and passive range of motion exercises, despite the resident's diagnosis of respiratory failure and cognitive intactness. The deficiency was confirmed through observation, record review, and interviews with facility staff.
The facility failed to administer oxygen therapy according to physician's orders for two residents. One resident received 2 lpm instead of the ordered 3 lpm, and another received 1 lpm instead of 2 lpm. These discrepancies were confirmed by an LPN, despite the facility's policy requiring verification of physician's orders.
A resident in the facility received medication incorrectly when an LPN crushed and mixed several medications, including Flomax, which was supposed to be swallowed whole according to physician orders. The resident, who was cognitively intact and had conditions such as hypertension and benign prostatic hyperplasia, was administered the medications in applesauce, contrary to the specified instructions. The LPN acknowledged the mistake upon review.
The facility failed to properly label, store, and dispose of medications in two of four medication carts inspected. An expired vial of Lantus insulin and improperly stored Xalatan eye drops were found on the first floor, while expired Timolol eye drops were found on the second floor. LPNs acknowledged these errors, which violated the facility's medication storage policy.
A facility failed to accurately code a resident's MDS, incorrectly indicating the presence of an ostomy when the resident had an indwelling catheter. The MDS Coordinator admitted the error, and the resident's care plan and medical records did not support the ostomy coding. Additionally, the facility did not properly assess and document the resident's vaccination status, despite the resident and Infection Preventionist providing information on past vaccinations.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Implement Dietary Preferences and Consistencies
Penalty
Summary
The facility failed to consistently implement dietary preferences and correct diet consistencies for three residents, leading to deficiencies in their care. Resident #8, who was on a regular diet with ground consistency, received a breakfast tray missing a pureed fruit cup and juice, and the coffee cake was not in the required pureed consistency. This resident, diagnosed with dysphagia and other conditions, was cognitively intact and expressed concerns about missing or incorrect items on their meal trays. Resident #19, on a regular diet with regular texture and thin liquids, frequently received meal trays missing requested items, such as cranberry juice, which was supposed to be provided with each meal. Despite being cognitively intact and having a care plan that included their beverage preferences, the resident's requests were not consistently met. The Registered Dietitian had documented these preferences, but they were not implemented effectively. Resident #51, on a consistent carbohydrate, no added salt diet with regular texture and thin liquids, also experienced missing items, such as prune juice, which was ordered for constipation prevention. The Food Services Director was unaware of these issues, and the facility's policy on tray accuracy was not followed, leading to these deficiencies. The Licensed Nursing Home Administrator acknowledged the problem but did not provide further information on corrective actions.
Deficient Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices, which could potentially lead to foodborne illnesses. During a kitchen tour, the surveyor, accompanied by the Food Service Director (FSD), observed several deficiencies. The juice dispensing machine had three out of six juice plastic tubes covered with a sticky substance, which the FSD acknowledged should be clean and free of debris. Additionally, the walk-in refrigerator had fans, fan grates, and panels covered with a dark-colored dust-like debris. In the walk-in freezer, there was a large buildup of ice and frost on the fans, walls, and ceiling, and the FSD could not provide an explanation for this occurrence. The facility's policies on dietary cleaning and food storage were reviewed, revealing that the dietary cleaning policy required a cleaning schedule to be developed and monitored by the dietary manager. However, the Licensed Nursing Home Administrator (LNHA) was unable to provide the most recent copy of the weekly deep cleaning list, which should have included tasks such as cleaning the freezers and refrigeration. The survey team discussed these concerns with the LNHA and Director of Nursing, but no further information was provided.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was observed using a nasal cannula connected to an oxygen concentrator at three liters per minute. The resident's medical record indicated a physician's order for oxygen at two liters per minute to maintain oxygen saturation above 92%, which was not reflected in the resident's care plan. Additionally, the care plan did not include the resident's participation in a restorative nursing program for passive range of motion exercises to both lower extremities, despite a physician's order for these exercises. The deficiency was identified through observation, interview, and record review by the surveyor. The resident was admitted with a diagnosis of respiratory failure unspecified by hypoxia and was assessed as cognitively intact. The facility's policy requires care plans to include measurable objectives and timetables to meet residents' needs, but the care plan for this resident did not reflect the necessary treatments and programs. The Director of Rehabilitation/Occupational Therapy confirmed the existence of the physician's order for the exercises, and the issue was discussed with the Licensed Nursing Home Administrator and the Director of Nursing, who did not provide further information.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's orders for two residents. Resident #30 was observed on two separate occasions receiving oxygen at 2 liters per minute (lpm) via nasal cannula, despite a physician's order for 3 lpm to maintain oxygen saturation above 92%. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) who checked the electronic Treatment Administration Record (eTAR) and verified the physician's order. Resident #30 was admitted with diagnoses including unspecified dementia and had a severely impaired cognitive status as indicated by a Brief Interview for Mental Status (BIMS) score of zero. Similarly, Resident #75 was observed receiving oxygen at 1 lpm via nasal cannula while having lunch, although the physician's order specified 2 lpm continuously. The LPN confirmed the resident was receiving 1 lpm, contrary to the order. Resident #75 was admitted with respiratory failure unspecified by hypoxia and was cognitively intact with a BIMS score of 15. The facility's policy on oxygen administration requires verification of the physician's order, which was not adhered to in these cases.
Medication Administration Error
Penalty
Summary
The facility failed to administer medication according to physician orders and acceptable standards of practice, as observed during a medication pass for a resident. The Licensed Practical Nurse (LPN) was seen crushing several medications, including Norvasc, Baclofen, Buspar, Cranberry, and Eliquis, and mixing them with applesauce. Additionally, the LPN opened a Flomax capsule and mixed its contents with the other medications, despite the physician's order specifying that Flomax should be swallowed whole with water and not crushed, opened, or chewed. The resident involved had a cognitive score indicating intact cognition and was admitted with diagnoses including hypertension, benign prostatic hyperplasia, and anxiety disorder. The physician's order for Flomax clearly stated that it should be administered whole, 30 minutes after a meal, which was not followed by the LPN. Upon review, the LPN acknowledged the error in medication administration. The facility's policy on administering medication requires adherence to physician orders, which was not met in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label, store, and dispose of medications in two of the four medication carts inspected. During the inspection of the first-floor medication cart #2, an opened vial of Lantus insulin was found to be expired. The LPN present acknowledged the expiration, stating that Lantus insulin has a 28-day expiration once opened. Additionally, on the first-floor medication cart #1, an unopened bottle of Xalatan eye drops was not dated and was improperly stored in the medication cart instead of the refrigerator. An opened vial of Lantus insulin on the same cart was also missing an opened date. The LPN acknowledged these storage and labeling errors. On the second-floor medication cart #2, an opened bottle of Timolol eye drops was found to be expired. The LPN present confirmed the expiration and acknowledged that the medication should have been removed from the cart. The facility's policy on medication storage, which prohibits the use of outdated drugs and requires proper storage and labeling, was not adhered to. The surveyor discussed these concerns with the Licensed Nursing Home Administrator and the DON, but no additional information was provided.
Inaccurate MDS Coding and Vaccine Assessment
Penalty
Summary
The facility failed to accurately reflect the status of a resident in the Minimum Data Set (MDS), which is a critical assessment tool for managing care in compliance with federal guidelines. The deficiency was identified when a surveyor observed a resident with an indwelling catheter, yet the MDS inaccurately coded the resident as having an ostomy. This coding error was confirmed by the MDS Coordinator/Registered Nurse, who admitted it was a mistake and that there was no documentation in the medical records indicating the presence of an ostomy. Additionally, the resident's care plan and physician's progress notes did not reflect any ostomy, further highlighting the inaccuracy in the MDS coding. The report also identified a failure to assess and document the resident's vaccination status accurately. The MDS indicated that the influenza and pneumococcal vaccines were not assessed, despite the resident stating they received the influenza vaccine annually and the Infection Preventionist confirming a history of receiving both vaccines. The MDS Coordinator/Registered Nurse could not recall why the vaccination data was not assessed or documented, despite following the RAI Manual's guidelines for vaccine assessment. This lack of accurate documentation and assessment in the MDS represents a significant deficiency in the facility's compliance with federal guidelines.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Boonton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oaks At Denville, The | 2.5 mi | ★★★★★ | 1 | 1 |
| Careone At Parsippany | 4.2 mi | ★★★★★ | 14 | 0 |
| Troy Hills Center | 5.1 mi | ★★★★★ | 3 | 0 |
| Lincoln Park Renaissance | 6.3 mi | ★★★★★ | 16 | 0 |
| Lincoln Park Care Center | 6.4 mi | ★★★★★ | 44 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.