Friendship Village of Tempe

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an incident involving abuse between a staff member and one resident (#30) was reported in a timely manner. The deficient practice could result in continued staff to resident abuse.

Inspectors wroteBased on clinical record review, staff interviews, observations, and facility documentation, staff interviews and policy review, the facility failed to ensure professional standards of quality were met regarding accurate documentation for one of three sampled residents (#24). The deficient practice could result in residents' clinical record not being accurate and complete.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the abuse policy was followed regarding an incident of abuse between a staff member and one resident (#63). The deficient practice could result in continued staff to resident abuse.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an incident involving abuse between a staff member and one resident (#63) was reported in a timely manner. The deficient practice could result in continued staff to resident abuse.

Inspectors wroteBased on observation, clinical record review, facility documentation, and staff interviews, the facility failed to ensure that one resident (#39) was not physically or sexually abused by another resident (#55).

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to develop and implement policies and procedures for documenting and reporting alleged violations involving abuse, in accordance with federal and state laws and regulations. The deficient practice resulted in an alleged violation concerning abuse not being documented in the residents' (#39 and #55) clinical records, and the allegation not being reported within the mandatory two-hour timeframe to Adult Protective Services (APS) and the State Agency. This deficient practice could result in further allegations not being documented or reported in a timely manner, which could impact residents' quality of life and care.

Inspectors wroteBased on clinical record reviews, facility documentation, and staff interviews, the facility failed to ensure that an alleged violation involving abuse (involving Resident #39 and Resident #55) was reported to the State Agency and Adult Protective Services (APS) within the required timeframe of two hours.

Inspectors wroteBased on observation, clinical record review, facility documentation, and staff interviews, the facility failed to ensure that adequate supervision was provided to one resident (#14) to prevent elopement from the facility. The deficient practice resulted in one resident leaving the building without notice, and could result in other residents going missing and/or getting injured.

Inspectors wroteBased on clinical record review, interviews and facility documentation and policy review, the facility failed to ensure that Activity of Daily Living (ADL) care was provided for 1 resident (#2). This deficiency could result in psychosocial harm, and skin breakdown.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure that one resident (#154) was free from unnecessary medications by failing to ensure pain medications were administered as ordered by the physician and following the ordered parameters. The deficient practice could result in the resident receiving unnecessary medication and being overmedicated.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure that food was stored under sanitary conditions. The deficient practice could result in foodborne illnesses.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure proper infection control were followed and maintained regarding placement of the catheter bag for one resident (#12) and, oxygen tubing for one resident (#155). The deficient practice could result in development and transmission of infections.

Inspectors wroteBased on observation, clinical record review and facility policy, the facility failed to ensure that staff respect and value the resident's private space by knocking and requesting permission before entering the room for one resident (#17). This deficient practice could result in resident rights not respected and honored.

Inspectors wroteBased on clinical record review, resident and staff interviews review of facility documentation and policy, the facility failed to ensure an alleged violation for one resident (#31) was reported to the State Agency (SA), Adult Protective Services (APS) and law enforcement. The deficient practice could result in compromised protection of the residents and appropriate action not taken.

Inspectors wroteBased on clinical record review, resident and staff interviews review of facility documentation and policy, the facility failed to ensure an alleged violation for one resident (#31) was thoroughly investigated. The deficient practice could result in compromised protection of the residents and appropriate action not taken.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that a written notification of transfer and the reason/s of the transfer was provided to the resident representative for one resident (#33); and failed to ensure a copy of that notice of transfer for one resident (#33) was sent to the long term care Ombudsman. The deficient practice could result in residents not having the added protection from being inappropriately transferred or discharged .

Inspectors wroteBased on clinical record review, staff interviews and facility policy, the facility failed to ensure that a medication was provided as ordered; and, failed to ensure that the physician was notified for a missed dose of antibiotic therapy for one resident (#104). The deficient practice could result in resident not receiving the treatment needed to meet his needs.

Inspectors wroteBased on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure scheduled medications were obtained and administered accurately for one resident (#24) of four sampled residents. The deficient practice could result in medications not being available for residents and medications not administered according to physician's orders.

Inspectors wroteBased on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure the clinical record was accurate for one resident (#24) The deficient practice could result in resident receiving inappropriate care and treatment.

Inspectors wroteBased on documentation, staff interviews, and facility procedures, the facility failed to ensure that the information posted on the daily staff posting was complete and correct.

Inspectors wroteBased on review of clinical records and policy, and staff interviews the facility failed to ensure an order for pain medication was followed as prescribed for Resident #32 by failing to administer medication within the physician ordered parameters. The deficient practice of administering unnecessary medication may result in undesirable medication-induced harm. Resident #32 was admitted into the facility on August 8, 2023 with diagnoses that included fracture of upper end of left humerus, pain, Alzheimer's, dementia, anxiety, and constipation. Review of the physician orders revealed the following: Morphine Sulfate Oral Solution 20 milligram (mg) / 5 milliliters (ml) (Morphine Sulfate) to give 0.125 milliliters sublingually every 4 hours as needed for pain 4-10 with start date of August 21, 2023. [...]