Inspection·July 20, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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). (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 366476 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village of the Falls 25920 Elm Street Olmsted Falls, OH 44138 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)