Friendship Village of Bloomington

Inspectors wroteBased on interview and document review, the facility failed to assess a resident's supervision needs, evaluate interventions, and revise the care plan following a significant incident for 1 of 3 residents (R1) reviewed for supervision and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented appropriate infection prevention and control practices, including proper hand hygiene while feeding residents, maintaining a clean resident care environment when staff were observed standing on a resident's (R6) mattress, and ensuring resident care items were cleanable and disinfected for a resident (R1) who had pool noodles affixed with tape on their bed and windowsill.

Inspectors wroteBased on interview and document review, the facility failed to ensure timely completion of a required annual Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed (R7), which had the potential to result in inaccurate assessment data and/or improper care planning.

Inspectors wroteBased on interview and document review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for BiPAP machine (noninvasive ventilatory device that helps patients breath by delivering two levels of air pressure: higher pressure during inhalation and lower pressure during exhalation).

Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive care plan was developed and maintained to ensure appropriate care was provided for 3 of 5 residents (R59, R3 and R12) reviewed for comprehensive care plan.

Inspectors wroteBased on interview and record review, the facility failed to update the care plan with identified and personalized nonpharmacological pain interventions for 1 of 1 residents (R3) reviewed for pain, failed to update fall interventions for 1 of 2 residents (R5) reviewed for accidents, and failed to update transfer ability for 1 of 1 residents (R6) reviewed who was identified as high risk for falls.

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop and/or implement a process to ensure coordination with hospice and ensure skin was accurately evaluated/monitored to promote healing and reduce the risk of complications (i.e., worsening) for 1 of 1 resident (R12) reviewed for skin alterations. In addition, the facility failed to ensure comprehensive monitoring was developed and completed for 1 of 1 residents (R9) reviewed with extensive, unilateral knee swelling.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff were following fall risk interventions for 1 of 1 (R6) resident identified at risk for falls to prevent further falls.

Inspectors wroteBased on interview and document review, the facility failed to ensure proper orders were obtained and adequate coordination in place to care for a resident with a suprapubic catheter for 1 of 1 residents (R3) reviewed who used a catheter.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate orders, accurate and complete respiratory care documentation and resident-specific ordered settings for the use and management of a BIPAP device (bilevel positive airway pressure device - a non-invasive ventilation machine to help breathing) for 1 of 1 resident (R59) reviewed for respiratory care.

Inspectors wroteBased on interview and document review, the facility failed to ensure the consulting pharmacist recommendations were fully addressed, including providing a rationale in the resident's medical record if no changes in medication were to be made for 1 of 5 residents (R5) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to inform in advance and obtain consent for psychotropic medication use for 1 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure activities of daily living (ADLs) were completed, including shaving for 1 of 1 resident (R22) reviewed for grooming.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure wounds were accurately assessed and reported appropriately when thought to be deteriorating for 1 of 3 residents reviewed for wound assessment and monitoring.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure hand hygiene was performed for 1 of 3 residents (R24) observed during personal cares and 1 of 1 residents (R24) observed during wound cares. Furthermore, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 residents (R24) observed for EBP.

Inspectors wroteBased on observation, interview and document review, the facility failed to thoroughly investigate injuries of unknown origin for 4 of 4 residents (R46, R18, R57, and 30) who had bruises where the injury was not witnessed, the resident could not explain the injury and the bruises were suspicious. The facility's pattern of failure to investigate injuries of unknown origin constituted an immediate jeopardy (IJ) situation. The IJ began on 3/26/24, when R46 was identified with a 2.4 centimeter (cm) x 2.6 cm inner thigh bruise and continued 3/27/24 when R18 was identified with a 7 cm x 5 cm facial bruise, 4/2/24 when R30 was identified with a 10 cm calf bruise, and 4/11/24 when R57 was identified with a 5.5 cm x 4 cm wrist bruise. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to recognize and report injuries of unknown origin to the administrator and/or the State Agency (SA) for 4 of 4 residents (R18, R57, R30, and R46) with suspicious bruises.

Inspectors wroteBased on observation, interview and record review, the facility failed ensure transfer interventions were consistently implemented for 1 of 1 resident (R18) reviewed for injuries of unknown origin. Additionally, the facility failed to implement interventions for monitoring and documenting bruising for 2 of 2 residents (R30 and R46) reviewed for injuries of unknown origin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and monitor the bruise on R18's left facial area, R46's right and left forearm, right and left anterior legs, and right and left inner thigh and failed to accurately document the location and monitor R30's bruise of unknown origin of four residents reviewed for quality of care.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely assistance with repositioning to minimize the development of pressure ulcer risk for 1 of 1 resident (R18) in accordance with the individualized care plan.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide adequate supervision during the provision of care for 1 of 1 residents (R18) observed to be transferred inappropriately and had an injury of unknown origin. In addition, the facility failed to provide adequate supervision including an assistance devices, anti-roll back, timely for R46.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely assistance with incontinence cares for 1 of 1 resident (R18) in accordance with the individualized care plan.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide nonpharmacological interventions prior to the administration of as needed antianxiety medications for 1 of 1 resident (R18) utilizing antianxiety medications.

Inspectors wroteBased on interview and document review, the facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of facility-initiated transfers for 12 of 12 residents (R72, R19, R175, R27, R45, R174, R12, R47, R173, R69, R171, R44) who had been hospitalized .