A list of the most recent deficiencies for Friendship Manor. 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? |
|---|---|---|---|---|
| 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 | 2023-07-19 | 2023-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-19 | 2023-08-11 | 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 | 2023-07-19 | 2023-08-09 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-07-18 | 2023-07-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-18 | 2023-07-19 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-07-18 | 2023-07-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-16 | 2023-05-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-08 | 2023-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-06 | 2022-10-31 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-09 | 2022-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-09 | 2022-05-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-09 | 2022-05-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-09 | 2022-05-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-09 | 2022-05-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-09 | 2022-05-27 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-09 | 2022-05-27 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-09 | 2022-05-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-05-09 | 2022-05-24 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-02-19 | 2021-05-01 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-02-19 | 2021-05-01 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-02-19 | 2021-05-01 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-02-19 | 2021-05-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-02-19 | 2021-05-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-02-19 | 2021-05-01 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-02-19 | 2021-03-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-02-19 | 2021-03-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-19 | 2021-03-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-19 | 2021-03-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-02-19 | 2021-02-19 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-02-19 | 2021-02-19 | N |
