A list of the most recent deficiencies for Friendship Village Sunset Hills. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-28 | 2023-11-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-28 | 2023-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-11-12 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-09-28 | 2023-11-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-28 | 2023-11-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-11-12 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-28 | 2023-11-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-01 | 2022-07-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-28 | 2019-10-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-28 | 2019-10-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-28 | 2019-10-04 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-08-28 | 2019-10-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-28 | 2019-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-28 | 2019-10-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-28 | 2019-10-04 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-07-16 | 2018-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-16 | 2018-08-10 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2018-07-16 | 2018-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-16 | 2018-08-10 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-07-16 | 2018-08-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-07-16 | 2018-08-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-16 | 2018-08-10 | N |
