Village of the Falls

In the surveyor’s words

From the most serious findings on record at Village of the Falls, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 20, 2023

  Based on observation, staff interview, and policy review the facility failed to ensure foods were stored in a clean and sanitary manner to prevent contamination and food borne illness. This had the potential to affect all residents. The facility census was 31. Findings include: During the initial kitchen tour with Dining Services Manager (DSM) #531 on 07/18/23 between 8:32 A.M. and 8:47 A.M. the following observations were made and verified at the time of discovery. In the walk-in freezer the following was observed: A plastic bag of egg omelets was open, exposed to the air, and not dated. A plastic bag of sausage patties was open, exposed to the air, and not dated and showed noticeable freezer burn. […]

• No harm, potential for more than minimal, isolatedF578Jul 20, 2023

  Based on interview, record review, and facility policy review, the facility failed to ensure Resident #23 had an accurate and consistent advance directive in place throughout the medical record. This affected one (Resident #23) of eight residents reviewed for advance directives. The facility census was 31. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included severe protein-calorie malnutrition, weakness, and adult failure to thrive. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 06 which indicated severely impaired cognition. […]

• No harm, potential for more than minimal, isolatedF641Jul 20, 2023

  Based on staff interview and record review, the facility failed to accurately code Resident #23's Minimum Data Set (MDS) 3.0 assessment. This affected one (Resident #23) of eight residents reviewed for accuracy of assessments. The facility census was 31. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included severe protein-calorie malnutrition, weakness, and adult failure to thrive. Review of the physician's orders revealed Resident #23 was admitted to hospice care on 05/16/23 with a diagnosis of end stage protein calorie malnutrition with life expectancy of six months or less if disease runs its normal course. […]

• No harm, potential for more than minimal, isolatedF849Jul 20, 2023

  Based on observation, interview, record review, and facility policy review the facility failed to ensure effective and ongoing communication with Resident #23's hospice company. This affected one (Resident #23) of two residents reviewed for hospice services. The facility census was 31. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included severe protein-calorie malnutrition, weakness, and adult failure to thrive. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 06 which indicated severely impaired cognition. […]

• No harm, potential for more than minimal, isolatedF582Dec 6, 2021

  Based on record review, staff interview, and review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), the facility failed to ensure Resident 23's wishes were honored for skilled services and payment for such services. This affected one (Resident #23) of four (Resident's #8, #13, #22 and #23) residents reviewed for skilled services. The facility census was 21. Findings include: Review of the medical record for the Resident #23 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing admission assessment dated [DATE] revealed Resident #23 transferred with supervision. […]