Friendship Village Sunset Hills

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity, in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life when staff failed to serve a requested alternate meal and told the resident to wait until the next meal (Resident #91), failed to serve a resident timely after the tablemates were served (Resident #109). The facility staff also failed to answer a resident after asking staff several times (Resident #44) and staff entered the resident rooms without knocking on the door (Residents #67, #102 and #110). The sample was 26. The census was 132. Review of the facility's Resident Rights: Accommodation of Needs and Preferences and Homelike Environment policy, dated August 2019, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each nurse aide had no less than twelve hours of in-service education per year based on their individual performance review and calculated by their employment date rather than the calendar year, for eight of 10 sampled Certified Nursing Assistants (CNA) and Certified Medication Technicians (CMT). The census was 132. Review of the facility's Compliance Education and Training Policy, dated 7/1/2019, showed: -Purpose: The purpose of this policy is to standardize the requirements for initial orientation, ongoing training, focus training, and corrective training in order to educate employees and non- employees on compliance with laws regulations and facility policies and procedures, and to promote accountability; -Policy statement: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation for ten out of ten narcotic count books reviewed. This had the potential to affect all residents with controlled substance orders. The census was 132. Review of the facility's Controlled Substances policy, original date 8/19, showed: It is the policy of Friendship Village to ensure compliance with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. -Only authorized licensed nurses that are permanent employees of Friendship Village or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors. Staff failed to administer a medication for one resident with a diagnosis of obstructive uropathy (occurs when urine flow is blocked, causing urine to build up in the kidneys) who required the medication to empty their bladder and increase urination (Resident #29). Staff failed to administer several doses of a medication used to treat anxiety for one resident (Resident #110). Staff also administered an expired medication, used to treat Parkinson's disease (an age-related degenerative brain condition) for over a week. The medication was ordered to be given twice a day. The bottle showed the medication expired October 2024 (Resident #227). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans were updated and accurate to reflect resident needs. This failure affected three of four sampled residents, whose care plan did not identify self-harm (Resident #96) sexual behaviors (Resident #109) and hospice services (Resident #29). The sample was 26. The census was 132. Review of the facility's Care Planning policy, dated August 2019, showed: -Policy: It is the policy of the facility for the Care Planning/Interdisciplinary Team to develop and to implement a person-centered comprehensive care plan for each resident to meet the resident's preferences and goals, and to address medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive care consistent with professional standards. Staff failed to complete a documented assessment and documented notifications to the physician and family regarding a resident's knee wound. Staff also failed to obtain a physician's order for a dressing to the resident's right knee (Resident #110). The sample size was 26. The census was 132. Review of the facility's Prevention and Treatment of Skin Breakdown policy, dated 8/2019, showed: -Policy: It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure injuries; To implement preventative measures; and to provide appropriate treatment modalities for wounds according to the industry standards of care. -Procedure: Monitoring of skin integrity. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, four errors occurred, resulting in a 13.33% error rate (Residents #60 and #98). Staff did not measure a medication in powder form on a level surface, provided a bottle of nasal spray to a resident and did not stop the resident at the ordered doses, crushed a medication that should not have been crushed and left crushed medications unattended on the medication cart. The census was 132. Review of the facility's Medication Administration, policy dated 8/19, showed: -Purpose: To clearly define Drug Administration policies in accordance with all applicable laws and standards of practice. Review of the facility's Crushing Medications policy, dated 8/19, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided therapeutic diets as recommended by the physician and the Registered Dietician (RD), for one resident with weight loss (Resident #109). The facility failed to provide the resident's fortified chocolate milk for two observed meals. The facility also failed to provide the extra items listed on the meal ticket. The sample was 26. The census was 132. Review of Resident #109's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Uses wheelchair for mobility; -Weight: 163 pounds (lbs); -Supervision or touching assistance for eating (Helper provides cues or touching/steadying assistance as resident completes activity); -Diagnoses include acid reflux, diabetes, malnutrition, dementia and depression. Review of the resident's current care plan, showed: -Problem: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection prevention and control when staff failed use proper hand hygiene while providing care for two of three sampled residents observed for incontinence care (Residents #110 and #44). The census was 132. Review of the facility's Hand Hygiene policy, dated 8/19, showed: -Purpose: hand hygiene is required in order to reduce the spread of potentially dangerous infectious agents and to reduce the risk of colonization or infection for health care workers that could be potentially acquired from the resident; -Policy Statement: It is the policy of this facility that hand hygiene will be provided consistent with best practices. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents was free from physical abuse by an agency Certified Nurse Aide (CNA). Review of a video, showed on the morning of 3/17/24, agency CNA A stood at Resident #1's bedside. He/She had one hand behind the resident's neck and with the other, pulled on the resident's leg towards a sitting position. The resident hit the CNA. With his/her right hand, CNA A punched the resident in the neck. He/She then loudly said, Stop. Why did you do that? The census was 136. On 04/12/24 9:49 A.M., the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 03/17/24. On 03/17/24, the administrator was notified of the incident and an investigation was started. CNA A was sent home and placed on the do not return list. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents, who had a change in condition, was monitored and assessed, according to professional standards, by a licensed nurse throughout the night. The resident was sent to the hospital the next morning, intubated (tube inserted through the mouth and into the lungs so the person can be placed on a ventilator to assist with breathing) in the emergency room (ER) for respiratory failure (a condition in which the blood does not have enough oxygen), and admitted to the intensive care unit (ICU) for respiratory failure, atrial fibrillation (an irregular and rapid heartbeat) and septic shock (the most severe complication of sepsis and carries a high mortality) (Resident #2). The census was 129. Review of the facility's Acute Change of Condition policy, dated 8/2019, showed: [...]

Inspectors wroteBased on observations, interviews, facility document review, and facility policy review, the facility failed to maintain 3 of 3 ice and water dispensers in the first, second, and third-floor beverage areas used for residents and staff. This had the potential to affect all 131 residents who resided in the facility at the time of the survey.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure medications were reconciled to ensure a safe discharge for 1 (Resident #229) of 3 sampled residents reviewed for discharge requirements.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to develop comprehensive care plans that addressed resident care needs for 2 (Resident #97 and Resident #229) of 27 sampled residents. Specifically, Resident #97 did not have a care plan to address their diagnosis of diabetes mellitus and use of insulin and Resident #229 did not have a care plan to address the use of an indwelling urinary catheter.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide services to residents who were unable to carry out activities of daily living (ADLs) necessary to maintain good grooming and personal hygiene for 1 (Resident #35) of 2 sampled residents reviewed for assistance with ADL care. Specifically, Resident #35 had fingernails that were long and dirty, and the resident did not receive showers according to their plan of care.

Inspectors wroteBased on interviews, record review, and facility document and policy review, the facility failed to investigate and determine causative factors of falls to help prevent and/or reduce the risk of further falls for 2 (Residents #429 and Resident #100) of 6 sampled residents reviewed for accidents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure pain medication was timely administered for 1 Resident #32) of 1 sampled resident reviewed for pain management.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure hand hygiene was performed during wound care for 1 (Resident #52) of 2 sampled residents reviewed for pressure ulcers/injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed physician's orders and the facility policy regarding elevated blood sugars. The facility identified 15 residents with orders for routine blood sugar checks (accu-checks). Of those 15, two had elevated blood sugars that exceeded the physician's parameters and the facility policy and problems were found with both (Residents #56 and #62). In addition, the facility failed to ensure staff completed the 72 hour fall follow-up neurological and vital sign form after two residents had falls with suspected head injuries (Residents #23 and #59). The census was 108 with 85 in certified beds. Review of the facility policy on hyperglycemia, dated 8/19, showed: Purpose: To prevent complications with hyperglycemia; Definition: -Hyperglycemia is the technical term for high blood glucose (blood sugar). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff thoroughly assessed and reassessed one resident's side rails/bed rails after staff found the resident's legs caught in the bed rail, causing a skin tear (Resident #52). In addition, seven of 18 additional sampled residents were observed with bed rails in use and problems were identified with all seven of those residents (Residents #25, #24, #35, #70, #275, #14 and #23). The census was 108 with 85 in certified beds. Review of the facility's Side Rails/Bed Rails Policy, dated August 2019, showed: -Preface: It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach will be used to achieve sustainable quality outcomes, including regular bed maintenance and individual bed rail evaluations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately assess residents for the use of bed rails/side rails and failed to implement appropriate interventions to prevent injuries for two of 18 sampled residents after sustaining injuries during the use of bed rails/side rails (Resident #52 and #35). The census was 108 with 85 in certified beds. 1. Review of Resident #52's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/22/19, showed: -Moderate cognitive impairment; -Extensive assistance of one person required for bed mobility and transfers; -Diagnoses included hip fracture and Parkinson's disease; -Two falls without injury and one fall with injury since admission; -Bed rails not used. Review of the resident's medical record, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rates are not 5 percent or greater. Out of 26 opportunities observed, there were three errors resulting in an 11.54% medication error rate (Resident #176). The census was 108 with 85 in certified beds. Review of the facility's policy on Medication Administration, dated 8/2019, showed: -Purpose: To clearly define drug administration policies in accordance with all applicable laws and standards of practice; -Policy: #7. All personnel administering medications will ensure that the medication is given: To the right person. The right medication - verified with physician order. The right dose - verified with physician order and standards of practice. The right time and the right route. Review of Resident #176's physician's order sheet (POS), dated August 2019, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff used acceptable infection control procedures during incontinence care for two of two observations (Residents #17 and #11). The census was 108 with 85 in certified beds. Review of the facility's policy on Standard precautions, undated, showed the following: -Purpose: It is the purpose of the facility to apply Standard Precautions to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases and apply to the care. Staff will be adequately trained in the various aspects of Standard Precautions to ensure appropriate decision making in various clinical situations; -Procedure: Gloves: #5. Change gloves as necessary, during care of a resident to prevent cross contamination from one body site to another (when moving from a dirty site to a clean one). #6. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue written Emergency Transfer notices to residents and/or representatives as soon as practicable when residents were temporarily transferred on an emergency basis to an acute care facility, and their return to the facility was expected (Residents #76 and #275). The census was 108 with 85 in certified beds. Review of the facility's Bed Hold Statement and Notice of Emergency Transfers, showed: -Upon admission to the facility and again if the resident is transferred to an acute care hospital, the resident (if able) or the responsible party is informed of the policy on bed holds. When a resident is transferred to the hospital, the resident (if able) or the responsible party will be contacted regarding their preference for bed hold. The responsible party or resident has the option of having the resident' bed held. [...]