A list of the most recent deficiencies for Friendship Manor Health Care. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-09 | 2024-02-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-01-09 | 2024-02-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-09 | 2024-02-09 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-09 | 2024-02-09 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-09 | 2024-02-09 | 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 | 2024-01-09 | 2024-02-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-09 | 2024-02-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-09 | 2024-02-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-01-09 | 2024-02-09 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-01-09 | 2024-02-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-11 | 2024-02-05 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-01-11 | 2024-02-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-11 | 2024-02-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-11 | 2024-02-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-11 | 2024-01-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-31 | 2023-11-22 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-09-21 | 2023-10-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-21 | 2023-10-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-21 | 2023-10-13 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-08-14 | 2023-09-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-14 | 2023-09-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-08 | 2023-09-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-08 | 2023-09-08 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-08-08 | 2023-09-08 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-01 | 2023-03-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-01 | 2023-03-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-01 | 2023-03-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-01 | 2023-03-27 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-03-01 | 2023-03-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-01 | 2023-03-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-03-01 | 2023-03-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-01 | 2023-03-23 | 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 | 2023-03-01 | 2023-03-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-01 | 2023-03-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-09 | 2022-12-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-23 | 2022-10-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-14 | 2022-10-01 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-12 | 2022-06-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-12 | 2022-06-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-05-12 | 2022-06-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-12 | 2022-06-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-12 | 2022-06-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-12 | 2022-06-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-21 | 2022-05-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-21 | 2022-05-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-16 | 2021-10-01 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-09-16 | 2021-10-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-16 | 2021-10-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-02 | 2021-09-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-06 | 2021-04-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-06 | 2021-04-13 | Y |
