Deficiency Records for Friendship Manor Nursing and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Friendship Manor Nursing and Rehab Center. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-24 | 2024-02-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-22 | 2023-03-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-22 | 2022-11-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-11 | 2022-09-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-08-11 | 2022-09-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-08-15 | 2022-08-29 | N |
| Use approved construction type or materials. | Fire Safety | 2022-08-15 | 2022-08-29 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-08-15 | 2022-08-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-15 | 2022-08-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-15 | 2022-08-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-15 | 2022-08-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-15 | 2022-08-29 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-08-26 | 2021-09-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-19 | 2021-09-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-27 | 2021-06-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-28 | 2021-05-21 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-30 | 2019-07-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-04-30 | 2019-07-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-30 | 2019-07-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-30 | 2019-07-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-30 | 2019-07-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-30 | 2019-07-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-14 | 2019-04-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-14 | 2019-04-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-14 | 2019-04-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-14 | 2019-04-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-03-14 | 2019-04-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-14 | 2019-04-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-03-14 | 2019-04-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-14 | 2019-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-14 | 2019-04-05 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-06-07 | 2018-06-26 | N |
| Develop a communication plan. | Fire Safety | 2018-06-07 | 2018-06-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-06-07 | 2018-06-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-06-07 | 2018-06-26 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2018-04-05 | 2018-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-05 | 2018-05-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-05 | 2018-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-05 | 2018-05-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-04-05 | 2018-05-15 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-04-05 | 2018-05-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-04-05 | 2018-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-05 | 2018-05-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-13 | Not Fixed | Y |
