Friendship Village

Inspectors wroteBased on interview and record review the facility failed to revise care plans timely for 2 (Residents #47 and #23) of 12 residents reviewed for person-centered care plans resulting in an inaccurate reflection of residents' care needs and the potential for incorrect care to be provided.

Inspectors wroteBased on observation, interview, and record review the facility failed to 1. Implement enhanced barrier precautions related to wound care for 1 (Resident #4) of 3 residents reviewed for wound care and 2. Ensure the use of personal protective equipment during high contact care activities for a resident in enhanced barrier precautions for 1 (Resident #58) of 2 resident reviewed for the activities of daily living resulting in the potential for the spread of infection, cross contamination, and disease transmission.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a dignified dining experience for 2 (Resident #14 and #21) of 2 residents reviewed for dignity resulting in the potential for feelings of diminished self-worth, sadness, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement care plan interventions for 2 (Resident #30 and Resident #21) of 12 residents reviewed for care plan implementation, resulting in the potential for skin breakdown for Resident #30 who's heel protectors (a padded cushion for a heel to rest in to prevent pressure caused from a heel resting directly on a mattress) not being consistently applied while in bed and Geri sleeves (sleeves worn to protect fragile skin from tearing) not being consistently applied for Resident #21 and Resident #30, and Resident #21 not consistently receiving a straw in her drinks at meals.

Inspectors wroteBased on interview and record review, the facility failed to revise the nutrition care plan of one resident (Resident #344) of 12 residents reviewed for comprehensive care plans resulting in confusion regarding the diet and fluid restriction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with eating for 1 (Resident #5) of 12 residents reviewed for activities of daily living (ADL) care resulting in the potential for avoidable negative physical outcomes for resident's who are dependent on staff for assistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure gait belt (a strap with a buckle that helps residents who have trouble walking or standing. Gait belts are used to support patients and help them move safely) use while ambulating one resident (Resident #343) of two residents reviewed for falls resulting in a fall and potential for injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate oxygen administration via nasal cannula (a tube with prongs into the nostrils of the nose to deliver additional oxygen to a body's blood) to 1 (Resident #4) of 1 reviewed for respiratory care, resulting in the resident not consistently receiving her oxygen at the level ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document meal intake for 2 (Resident #5 and Resident #30) of 12 residents reviewed for complete and accurate medical records resulting in an inaccurate reflection of the resident's meal intakefor Resident #5 and an inaccurate reflection of care provided for Resident #30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, date, and discard opened food products. These conditions resulted in an increased risk of food borne illness that affected all residents who consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to submit complete and accurate direct care staffing data for the 4th quarter of 2023 (July, August, and September).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for (1) documentation of medication administration in 3 of 7 residents (Resident #1, #37, & #145) reviewed for medication administration, and (2) medication handling/storage in 1 of 8 residents (Resident #3) reviewed for medication storage, resulting in medications being left unsupervised at the bedside, and the potential for medication errors.

Inspectors wroteThis citation has two Deficiency Practice Statements, 1 & 2. Deficiency Practice Statement 1: Based on observation, interview, and record review, the facility failed to: (1) perform hand hygiene when moving between resident rooms after performing resident care; (2) sanitize resident shared equipment between resident use; (3) wear appropriate PPE (personal protective equipment) while sorting soiled laundry, including laundry from transmission-based precaution isolation rooms; and (4) implement precautions and utilize appropriate PPE per physician order in 1 of 3 residents (Resident #3) reviewed for transmission-based precautions. These deficient practices resulted in the potential for cross-contamination, disease exposure, and the development and spread of infection to a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for a high-risk medication for 1 (Resident #32) of 13 sampled residents reviewed for care plans, resulting in an incomplete reflection of the residents' care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe transport of a resident in a wheelchair footrests were in place, or properly used, in 1 (Resident #6) of 13 sampled residents, resulting in the potential for an accident or an injury to occur during transport.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper care and services related to tube feeding management in 1 (Resident #3) of 1 resident reviewed for tube feeding management, resulting in the potential for decreased feeding tube patency, feeding tube damage, and/or resident infection or injury.