A list of the most recent deficiencies for Friendship Village. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-27 | 2024-04-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-27 | 2024-04-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-27 | 2024-04-15 | 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 | 2024-02-27 | 2024-04-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-27 | 2024-04-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-27 | 2024-04-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-27 | 2024-04-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-27 | 2024-04-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-27 | 2024-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-27 | 2024-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-29 | 2024-04-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-29 | 2024-04-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-29 | 2024-04-09 | 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 | 2024-02-29 | 2024-04-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-29 | 2024-04-09 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-02-29 | 2024-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-29 | 2024-04-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-01 | 2023-07-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-15 | 2023-04-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-15 | 2023-04-30 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-03-15 | 2023-04-30 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-15 | 2023-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-15 | 2023-04-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-15 | 2023-04-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-15 | 2023-04-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-03-15 | 2023-04-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-15 | 2023-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-15 | 2023-04-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-15 | 2023-04-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-15 | 2023-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-15 | 2023-04-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-01 | 2022-01-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-01 | 2022-01-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-12-01 | 2022-01-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-01 | 2022-01-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-02 | 2022-01-10 | 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 | 2021-12-02 | 2022-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-25 | 2021-09-30 | Y |
