Every finding on record at Village of the Falls

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. A plastic bag of hamburger patties was open, exposed to the air, and not dated and showed noticeable freezer burn. A box of frozen vegetables was open, exposed to air, and not dated. A box of cod filets was open, exposed to the air, and not dated and showed noticeable freezer burn. In the walk-in refrigerator the following was observed and verified at the time of discovery. A box of yellow onions was in the refrigerator revealed the onions were soft and multiple onions had begun to show signs of rot. Observation of the door outside the walk-in in refrigerator noted a laminated sheet of paper taped to the door with a red stop sign reminding staff of proper food storage practices including asking the question Is it labeled? Review of the policy dated 10/01/14 titled Food Stock Rotation revealed any item opened must be dated with the opening date and wrapped after opening.

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. The MDS reflected Resident #23 required extensive assistance of one staff for dressing, personal hygiene, and bed mobility. Resident #23 was dependent with two staff for transfers and was unable to ambulate. Review of Resident #23's care plan revealed a code status of Do Not Resuscitate Comfort Care Arrest (DNRCC-Arrest). Review of 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 natural course. Resident #23 had a code status order, dated 07/05/22, of DNRCC-Arrest. Review of the Do Not Resuscitate (DNR) Order Form in Resident #23's chart revealed a selection of DNRCC-Arrest, dated 07/05/22, and signed by Resident #23's physician. The form stated providers will treat patients as any other without a DNR order until the point of cardiac or respiratory arrest, at which point all interventions will cease and the DNR Comfort Care protocol will be implemented. Interview on 07/18/23 at 8:47 A.M. with Director of Nursing (DON) revealed Resident #23 had received comfort care from staff and was actively dying. DON verified Resident #23 had a current order for a code status of DNRCC-Arrest and had not received any intervention to prolong or sustain life. DON stated Resident #23 should have had a code status of DNRCC. Review of the Hospice Interdisciplinary Group Meeting note dated 05/24/23 and timed 09:00 A.M. revealed Resident #23 was listed as a DNR Comfort Care (DNRCC). Interview on 07/18/23 at 2:00 P.M. with Hospice Registered Nurse (RN) #610 revealed hospice records listed Resident #23's code status of DNRCC. Hospice RN #610 accessed Resident #23's hospice records on her work tablet and revealed a signed DNRCC form dated 05/17/23, signed by the hospice medical director. Hospice RN #610 verified Resident #23 had been receiving comfort care at the facility and was actively dying. Interview on 07/18/23 at 2:18 P.M. with DON revealed the facility had no record of a DNRCC form dated 05/17/23. DON verified Resident #23's medical record was inconsistent, as the facility and hospice provider had different code status records for Resident #23. DON stated there was a breakdown in communication between the facility and the hospice provider and was not sure how it happened. Review of the facility policy titled Advanced Directive Policy and Procedure, dated 01/2022, stated each resident's advance directives are documented accurately in the record to allow for accurate verification at the time when the directive would be implemented.

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. The MDS reflected Resident #23 required extensive assistance of one staff for dressing, personal hygiene, and bed mobility. Resident #23 was dependent with two staff for transfers and was unable to ambulate. Review of Resident #23's care plan revealed a code status of Do Not Resuscitate Comfort Care Arrest (DNRCC-Arrest). Review of 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 natural course. Resident #23 had a code status order, dated 07/05/22, of DNRCC-Arrest. Review of the Do Not Resuscitate (DNR) Order Form in Resident #23's chart revealed a selection of DNRCC-Arrest, dated 07/05/22, and signed by Resident #23's physician. The form stated providers will treat patients as any other without a DNR order until the point of cardiac or respiratory arrest, at which point all interventions will cease and the DNR Comfort Care protocol will be implemented. Interview on 07/18/23 at 8:47 A.M. with Director of Nursing (DON) revealed Resident #23 had received comfort care from staff and was actively dying. DON verified Resident #23 had a current order for a code status of DNRCC-Arrest and had not received any intervention to prolong or sustain life. The DON stated Resident #23 should have had code status of DNRCC. Review of the Hospice Interdisciplinary Group Meeting note, dated 05/24/23 and timed 09:00 A.M., revealed Resident #23 was listed as a DNR Comfort Care (DNRCC). Observation on 07/18/23 at 1:33 P.M. revealed Resident #23 in bed and appeared comfortable. Hospice staff and multiple family members were observed in Resident #23's room. Soft music played in the background. Resident #23 appeared unresponsive to the visitors and activity in the room. Interview on 07/18/23 at 2:00 P.M. with Hospice Registered Nurse (RN) #610 revealed hospice records listed Resident #23's code status as DNRCC. Hospice RN #610 accessed Resident #23's hospice records on her work tablet and revealed a signed DNRCC form dated 05/17/23 and signed by the hospice medical director. Hospice RN #610 verified Resident #23 had been receiving comfort care at the facility and was actively dying. Interview on 07/18/23 at 2:18 P.M. with the DON revealed the facility had no record of a DNRCC form dated 05/17/23. The DON verified Resident #23's medical record was inconsistent, as the facility and hospice provider had different code status records for Resident #23. The DON stated there was a breakdown in communication between the facility and the hospice provider and was not sure how it happened. Interview on 07/18/23 at 4:18 P.M. with the DON revealed code status is very important to communicate, and social services coordinates and addresses code statuses of residents on a routine basis and during care conferences. The DON stated social services coordinated the care conference meetings. The DON was unsure how often care conferences were held or if hospice staff had been invited routinely. Observation on 07/19/23 at 8:19 A.M. revealed Resident #23 in bed, appeared comfortable and in no visible distress. Licensed Practical Nurse (LPN) #508 was at bedside and stated that Resident #23 remained unresponsive, but stable. Interview on 07/19/23 at 9:40 A.M. with Social Services Director (SSD) #539 revealed she coordinated the care conference schedule. Care conferences were held on admission, quarterly, if there was an increased need, and following a significant change. Interview on 07/19/23 at 4:00 P.M. with Hospice RN #610 revealed she had not been invited to attend a care conference for Resident #23 since she admitted to hospice on 05/16/23. Review of the Care Conference Attendance form for Resident #23, dated 05/11/23, revealed the Licensed Practical Nurse Clinical Coordinator (LPN CC) #523 and SSD #539 were in attendance, and Resident #23's daughter attended via phone. A corresponding progress note dated 05/11/23 and timed 4:50 P.M. revealed Resident #23 was having increased pain and anxiety and family would like a hospice consult. Interview on 07/19/23 at 4:10 P.M. with LPN CC #523 and SSD #539 stated they held the phone conference to meet the needs of Resident #23's family member. SSD #539 verified no care conference had been scheduled since Resident #23 elected for hospice, and hospice staff had not been invited to attend a care conference with facility staff and Resident #23's family. Review of the policy titled Hospice, revised 08/2014, revealed a meeting will be held between hospice staff, facility staff, and family for care plan generation and continuity of care. Review of the facility policy titled Plan of Care Meetings Policy, dated 04/2022, revealed plan of care meetings are held following admission, at least quarterly, or with any significant change in condition. The policy further identified during the care plan meetings, advanced directives will be reviewed, and any changes indicated.

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. Review of section J of the MDS Significant Change in Status MDS assessment, dated 05/18/23, revealed the facility marked no to the resident having a condition or chronic disease that may result in a life expectancy of less than six months. Review of section O of the MDS revealed the facility had not marked hospice care under the section of special treatments, procedures and programs. Interview on 07/20/23 at 8:34 AM with Corporate MDS Nurse #600 revealed Resident #23 had a significant change in status assessment scheduled and completed after the resident elected for hospice. Corporate MDS Nurse #600 verified section J was incorrect as Resident #23 had a life expectancy of less than six months. Corporate MDS Nurse #600 verified section O was incorrect, and hospice care should have been marked. Corporate MDS Nurse #600 verified the MDS was not an accurate reflection of Resident #23's health status as of the assessment reference date of 05/18/23 and needed to be corrected.

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. Review of the Skilled Nursing Facility Advance Beneficiary Notice of non-coverage (SNFABN) dated and signed on 09/10/21 by Resident #23's power of attorney (POA) revealed the POA wanted the inpatient skilled nursing services and wanted Medicare to be billed for an official decision on payment, which would be sent to the POA on a Medicare Summary Notice (MSN). Resident #23's POA understood that if Medicare did not pay, the POA was responsible for paying, but could appeal to Medicare by following the directions on the MSN. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of PT screening on 09/13/21 at 11:30 A.M. revealed Resident #23 required assistance with transfers and was requesting PT and OT evaluation and treatment, stating he would be in the facility longer than one week. Nursing was uncertain of a discharge plan or planned length of stay. There was no further documentation whether Resident #23 would benefit from physical therapy. PT did not state why they did not refer Resident #23 for a PT evaluation. There was no documented evidence of why the PT screen ordered on 09/10/21 was not completed as ordered until 09/13/21. Review of the OT screen dated 09/13/21 at 12:03 P.M. revealed that Resident #23 was a new admission and recently sustained a fall. He required assistance for transfers and activities of daily living (ADL). Resident #23 was requesting OT and PT interventions stating he may be here longer than anticipate. Review of the PT screening on 09/15/21 revealed the facility referred Resident #23 to PT because of a fall on 09/14/21. PT screening recommended a PT and OT evaluation. Review of the PT screening on 09/16/21 revealed the facility referred the Resident #23 to PT because of a fall 09/14/21. PT screening recommended a PT and OT evaluation. The PT screening did not state why another screening was completed rather than the PT evaluation recommended on 09/15/21. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/17/21, revealed Resident #23 had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and ambulation. Resident #23 was not receiving therapy services during the seven-day look back period. Review of the Medicare Skilled assessment dated [DATE] at 10:15 A.M. revealed Resident #23 required extensive assistance with two staff and a mechanical lift was used for transfers. Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order was obtained for PT to treat for 12 sessions over four weeks for therapy, gait retraining, and neuro re-education. Review of the therapy notes from 09/13/21 through 09/23/21 revealed PT screenings were completed on 09/13/21, 09/15/21, and 09/16/21 with no indication that and evaluation and/or treatment occurred. Resident #23 had a PT evaluation on 09/23/21. Review of PT notes revealed that the first evaluation for PT was dated 09/23/21. The Summary of Skilled section, Resident #23 was referred to PT services at the facility post admission from assisted living due to confusion, change in mental status, and urinary tract infection. Resident #23 was currently functioning significantly below his baseline and could benefit from PT services to address deficits and facilitate a safe return to a home environment with his daughter. Review of emails from therapy dated 09/20/21 at 11:39 A.M. revealed the Former Director of Rehabilitation #206 received an email from the facility stating they just got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23 was at the facility to receive an intravenous (IV) antibiotic but had recently required a Hoyer lift (mechanical lift) for transfers. The POA was aware it would be private pay but wanted Resident #23 to be evaluated by both PT and OT. Review of emails from therapy dated 09/22/21 at 3:26 P.M. revealed the Former Director of Rehabilitation #206 sent an email to the facility stating he followed up with the POA of Resident #23 and was looking at an OT evaluation tomorrow (09/22/21) and PT evaluation on Friday (09/24/21). Former Director of Rehabilitation #206 stated he reviewed the therapy plan and informed the POA the therapist would call her after evaluation to review goals and Resident #23's prior level of function. The POA discussed Resident #23's recent stay and decline. OT tried multiple times last week and Resident #23 wasn't appropriate per OT as Resident #23 wasn't engaging in the evaluation and was difficult to assess. OT could attempt again this week if Resident #23 was staying, but OT was not sure of the potential though it seemed poor at this time. Interview on 12/03/21 at 1:58 P.M. with Director of Rehabilitation #207 revealed Resident #23 received therapy services for two days (09/23/21 and 09/24/21), and Physical Therapist #210 was on maternity leave who worked with the Resident #23. He stated according to the therapy notes, Resident #23 was admitted for IV antibiotic therapy and was directly admitted from assisted living. Prior to admission, insurance verification was completed to determine if Resident #23 was eligible for either Medicare part A or Medicare part B in relation to therapy services. Director of Rehabilitation #207 could not state why Resident #23 did not receive therapy prior to 09/23/21 but had emails stating Resident #23 refused OT. Review of Resident #23's medical record for September 2021 revealed no documented evidence of refusal of therapy services. Phone interview on 12/03/21 at 11:36 A.M. with Corporate Business Office Billing #208 revealed Resident #23 came into the facility after a three day stay in the hospital. Resident #23 required skilled services, and a skilled nursing facility was safer because of COVID-19. Upon admission, the POA of Resident #23 was required to pay for a month in advance for skilled services. Corporate Business Office Billing #208 stated the facility did not submit paperwork to Medicare for Resident #23, we dropped the ball. Resident #23's chart was reviewed earlier in the morning (12/03/21) and it revealed that Resident #23 did not receive the services he was charged for and will be refunded the money. This deficiency substantiates Complaint Number OH 72.

Based on observation, record review and interview the facility failed to provide physician ordered physical therapy services in a timely manner to maintain Resident #23's ability to perform activities of daily living (ADL). This affected one (Resident #23) of three (Resident's #8, #13 and #23) reviewed for ADL care. 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. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physical therapy (PT) screening on 09/13/21 at 11:30 A.M. revealed Resident #23 required assistance with transfers and was requesting PT and OT evaluation and treatment, stating he would be in the facility longer than one week. Nursing was uncertain of a discharge plan or planned length of stay. There was no further documentation whether Resident #23 would benefit from physical therapy. PT did not state why they did not refer Resident #23 for a PT evaluation. There was no documented evidence why the PT evaluation ordered on 09/10/21 was not completed as ordered. Review of the PT screening on 09/15/21 revealed the facility referred Resident #23 to PT because of a fall on 09/14/21. PT screening recommended a PT and OT evaluation. Review of the PT screening on 09/16/21 revealed the facility referred the Resident #23 to PT because of a fall 09/14/21. PT screening recommended a PT and OT evaluation. The PT screening did not state why another screening was completed rather than the PT evaluation recommended on 09/15/21. Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed no therapy evaluation was completed as ordered from 09/10/21 through 09/22/21. Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the therapy notes from 09/13/21 through 09/23/21 revealed that PT screenings were completed on 09/13/21, 09/15/21, and 09/16/21 with no indication an evaluation and/or treatment occurred. Resident #23 was evaluated by PT on 09/23/21. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/17/21, revealed Resident #23 had intact cognition. Resident #23 required extensive assistance of two staff for bed mobility, transfers, ambulation which was s significant decline since admission on 09/10/21. The resident was not receiving therapy services during the seven-day look back period. Review of the Medicare Skilled assessment dated [DATE] at 10:15 A.M. revealed Resident #23 required extensive assistance of two staff and a mechanical lift for transfers. Interview on 12/03/21 at 1:58 P.M. with Director of Rehabilitation #207 verified Resident #23 did not receive a PT evaluation until 09/23/21. Director of Rehabilitation #207 stated he was hired a month ago, and Physical Therapist #210 was on maternity leave who worked with Resident #23. According to the therapy notes, Resident #23 was directly admitted from assisted living for IV antibiotic therapy. Prior to admission, insurance verification was completed to determine if Resident #23 was eligible for either Medicare part A or Medicare part B in relation to therapy services. Director of Rehabilitation #207 could not state why Resident #23 did not receive physician ordered therapy services prior to 09/23/21. Review of Resident #23's medical record for September 2021 revealed no documented evidence of refusal of therapy services. This deficiency substantiates Complaint Number OH 72.