Inspection Reports for
Friendship Village Tempe

Complaint investigation cited two deficiencies related to abuse reporting and medical record maintenance.

The complaint involved an incident on March 5, 2025, where Resident #30 was allegedly pulled out of bed roughly by a staff member. The facility reported the incident to Adult Protective Services, Police Department, and Arizona Department of Health Services on March 6, 2025, exceeding the required reporting timeframe. The allegation was substantiated as the facility acknowledged the delay in reporting. Another complaint involved verbal abuse toward Resident #24 on February 14, 2025, which was investigated but not documented in the clinical record.

The facility failed to report a staff-to-resident abuse incident involving Resident #30 in a timely manner, reporting it 24 hours after the incident occurred. Additionally, the facility failed to document allegations of verbal abuse involving Resident #24 in the clinical record, contrary to policy requiring documentation of all incidents.

Complaint investigation cited two deficiencies related to policies and procedures and abuse reporting.

The complaint involved an allegation that a Certified Nursing Assistant (CNA) threw a TV remote at Resident #63 and held his hand too tightly during care. The LPN who was informed of the allegation failed to report it immediately as required by facility policy. The facility investigation confirmed the delay in reporting and initiated corrective actions including suspension and termination of the LPN. The complaint was substantiated.

The facility failed to ensure the abuse policy was followed regarding an incident where a staff member allegedly threw a TV remote at Resident #63 and held his hand too tightly. The Licensed Practical Nurse (LPN) who received the abuse report did not timely report it to supervisors as required. The facility delayed investigation and reporting until approximately 12:30 p.m. the day after the incident. The facility suspended and terminated the LPN for failure to follow abuse reporting policy. The deficient practice could result in continued staff to resident abuse.

Complaint survey cited four deficiencies including policies and procedures, abuse reporting, resident abuse, and premises maintenance.

The complaint investigation was triggered by an alleged abuse incident on March 2, 2025, involving Resident #55 inappropriately touching Resident #39. Multiple staff witnessed the event and confirmed the abuse. The facility investigation revealed failure to report the incident within the mandatory two-hour timeframe to Adult Protective Services and the State Agency. The abuse was substantiated based on staff statements, video footage review, and interviews.

The facility failed to prevent and properly document abuse between residents #39 and #55, including inappropriate touching despite staff witnessing the event. The abuse was not reported within the required two-hour timeframe to Adult Protective Services and the State Agency. The facility also failed to provide adequate supervision to prevent elopement of Resident #14, who left the building unnoticed and was found across the street by security. Policies on abuse prevention and elopement were reviewed, revealing gaps in timely reporting and supervision.

Recertification survey for Medicare under Life Safety Code 2012 found no apparent deficiencies based on acceptance of a plan of correction.

The complaint investigation found that the resident missed a dose of Fosfomycin antibiotic and the physician was not notified as required. Interviews with nursing staff and the Director of Nursing confirmed the failure to notify and the lack of a facility policy on physician notification.

The facility failed to ensure that Fosfomycin antibiotic was administered as ordered to resident #104, missing the first dose on May 16, 2024, and failed to notify the physician of the missed dose. Interviews with nursing staff confirmed the medication was not available in the emergency kit and that notification procedures were not consistently followed. The facility lacked a policy on physician notification for missed doses.

The facility was found deficient in multiple areas including failure to respect resident privacy, failure to report and investigate alleged abuse, failure to notify resident representatives and ombudsman of transfers, inadequate assistance with activities of daily living, medication administration errors including unavailable medications and improper patch application, unsafe food storage practices, inaccurate clinical records, and improper infection control practices related to catheter bag and oxygen tubing placement.

Recertification and relicensure survey with complaint investigation cited 11 deficiencies including policies and procedures, abuse reporting, dignity, medication, care planning, and food storage.

The facility failed to ensure that daily nurse staffing postings were complete and accurate, with missing or incorrect information on registered nurse and licensed practical nurse staffing and hours worked. Additionally, the facility failed to administer pain medication to Resident #32 within the physician-ordered parameters, resulting in unnecessary medication administration.

Relicensing survey with complaint investigation cited four deficiencies including nurse staffing information, unnecessary drugs, and nursing personnel documentation.

Recertification survey for Medicare under Life Safety Code 2012 cited six deficiencies related to fire alarm system, sprinkler system, door maintenance, HVAC, and fire door inspection.

The facility was found deficient in multiple areas including failure to provide written notification of bed hold policy to residents or their representatives, failure to provide copies of baseline care plan summaries, and failure to administer medications strictly according to physician orders and document appropriately. Additionally, food safety issues were noted including moldy food items and unclean dishware.