A list of the most recent deficiencies for Friendship Village Retirement. 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? |
|---|---|---|---|---|
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-17 | 2023-09-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-17 | 2023-09-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-08-17 | 2023-09-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-17 | 2023-09-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-17 | 2023-09-17 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-08-17 | 2023-09-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-17 | 2023-09-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-17 | 2023-09-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-10 | 2023-08-30 | 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 | 2023-08-10 | 2023-08-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-10 | 2023-08-30 | 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 | 2023-08-17 | 2023-08-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-17 | 2023-08-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-17 | 2023-08-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-05 | 2022-06-24 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-04 | 2022-05-25 | 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 | 2022-05-05 | 2022-05-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-05 | 2022-05-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-05 | 2022-05-24 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-05-05 | 2022-05-24 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-04 | 2022-05-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-04 | 2022-05-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-30 | 2021-10-08 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-10-12 | 2020-12-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-12 | 2020-12-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-12 | 2020-12-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-12 | 2020-12-23 | 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 | 2020-10-14 | 2020-10-15 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-10-14 | 2020-10-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-10-14 | 2020-10-15 | N |
