Friendship Village Sunset Hills

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Apr 15, 2024

  Based 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. […]

• Actual harm, isolatedF684Feb 1, 2024

  Based 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). […]

• No harm, potential for more than minimal, widespreadF812Sep 28, 2023

  Based 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. Findings included: Review of the Nugget Ice Machines Installation, Operation and Maintenance Manual, revised in December 2017, indicated, If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. If required, an extremely dirty ice machine may be taken apart for cleaning and sanitizing. […]

• No harm, potential for more than minimal, patternF550Jan 28, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF730Jan 28, 2025

  Based 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… […]