A list of the most recent deficiencies for Friendship Haven, Inc. 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 | 2024-01-25 | 2024-02-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-18 | 2023-05-24 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-09-15 | 2022-10-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-16 | 2022-10-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-16 | 2022-09-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-16 | 2022-09-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-16 | 2022-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-16 | 2022-09-23 | 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 | 2022-09-16 | 2022-09-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-16 | 2022-09-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-16 | 2022-09-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-24 | 2021-07-07 | 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 | 2021-04-26 | 2021-05-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-26 | 2021-05-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-26 | 2021-05-13 | 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 | 2021-04-26 | 2021-05-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-26 | 2021-05-13 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-04-26 | 2021-05-13 | 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 | 2021-04-26 | 2021-05-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-26 | 2021-05-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-26 | 2021-05-13 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-23 | 2021-05-07 | N |
| Use approved construction type or materials. | Fire Safety | 2021-04-23 | 2021-04-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-23 | 2021-04-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-23 | 2021-04-23 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2021-04-23 | 2021-04-23 | 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 | 2019-07-15 | 2019-08-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-11 | 2019-08-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-07-11 | 2019-08-01 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-07-11 | 2019-08-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-07-11 | 2019-08-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-11 | 2019-08-01 | 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 | 2019-07-11 | 2019-08-01 | 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 | 2019-07-11 | 2019-08-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-07-11 | 2019-08-01 | 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 | 2019-07-11 | 2019-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-11 | 2019-08-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-07-15 | 2019-07-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-15 | 2019-07-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-15 | 2019-07-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-15 | 2019-07-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-15 | 2019-07-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-15 | 2019-07-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-15 | 2019-07-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-15 | 2019-07-16 | N |
