Friendship Village Retirement

In the surveyor’s words

From the most serious findings on record at Friendship Village Retirement, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 5, 2022

  Based on observations, clinical record reviews, and staff interviews, the facility failed to provide adequate nursing supervision for five of five residents reviewed (Resident #103, #25, #2, #41, and #16) to prevent a fall with injury. Resident #103 fell on [DATE], he had a severely impaired cognition level. No staff observed Resident #103's fall and took his word that he didn't hit his head. That night Resident #103 continued to complain of a headache all night. On [DATE], Resident #103 fell again documentation determined a skin tear to his right elbow with a bump on his head. At that time Resident #103 refused to go to the emergency room . On [DATE], his temperature went up and Resident #103 noted to have increased confusion. […]

• Actual harm, isolatedF689Jul 16, 2024

  Based on clinical record review, observations, staff, resident, and family interviews the facility failed to provide adequate supervision for 1 of 3 residents reviewed with falls (Resident #1). On 1/25/24, Resident #1 fell while receiving assistance from a Certified Nurse Aide (CNA). As the CNA assisted Resident #1 she failed to apply a gait belt. The fall resulted in a hip fracture to Resident #1's right hip that required surgical repair. The facility reported a census of 63. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a staff assessment for mental status. The assessment reflected Resident #1 had an ok short-term memory and could make independent decisions. Resident #1 required partial to moderate assistance with walking 10 - 150 feet. […]

• No harm, potential for more than minimal, patternF803Aug 10, 2023

  Based on observation, policy review, and staff interview, the facility failed to follow the menu and substitute menu item that wasn't available in the Community household. The facility reported a census of 68 residents. Findings include: Review of the lunch menu for the Community household dated 8/9/23 revealed broccoli almond salad was to be served. Observation 8/9/23 at 12:02 PM revealed two separate containers of broccoli almond salad with temperatures obtained by the Certified Dietary Manager (CDM) of 50.5 degrees and 43.7 degrees and cottage cheese with a temperature of 42.4 degrees prior to serving. The CDM stated the items were not going to make the appropriate temperatures of 41 degrees or below prior to being served. The CDM then removed the items from the serving kitchen. […]

• No harm, potential for more than minimal, patternF812Aug 10, 2023

  Based on observation, staff interviews, and policy review the facility failed to maintain adequate kitchen sanitation: failed to label and date food items; failed to store food in a sanitary manner; failed to maintain adequate temperature of the milk and cold items during meal service to reduce the risk of food-borne illnesses. The facility reported a census of 68 residents. Findings include: 1. An observation on [DATE] at 10:04 a.m. of the main food kitchen on the second floor noted moldy fruit in the walk-in cooler. A box of opened shredded lettuce and a box of shredded cheese along with 5 other boxes noted on the floor in the center of the cooler. The freezer noted to have 6 boxes of frozen food stored on the floor in the middle of the walkway. […]

• No harm, potential for more than minimal, patternF865May 5, 2022

  Based on staff interviews, clinical record reviews, and facility policy review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in an identified repeated concern during the current survey. The facility reported a census of 49 residents. Findings included: 1. The Facility's Self-Reported Incident dated 10/21/21, identified a fall in the facilities van. 2. Resident #41's Progress Notes dated 12/20/21, identified a fall from a full body lift. On 5/4/22 at 10:47 AM, the Administrator reported that the facility failed to address the fall (incidents) in the QAPI/ Quality Assurance and Assessment (QAA) process. […]