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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-26 | 2024-03-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-26 | 2024-03-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-27 | 2024-01-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-27 | 2024-01-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-29 | 2023-09-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-29 | 2023-09-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-29 | 2023-09-15 | Y |
| 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 | 2023-08-29 | 2023-09-15 | Y |
| 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 | 2023-08-02 | 2023-09-15 | Y |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-08-02 | 2023-09-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-28 | 2023-03-28 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-02-28 | 2023-03-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-28 | 2023-03-27 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-28 | 2023-03-27 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-28 | 2022-08-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-28 | 2022-08-23 | 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 | 2022-07-28 | 2022-08-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-28 | 2022-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-28 | 2022-08-23 | 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 | 2022-07-28 | 2022-08-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-28 | 2022-08-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-28 | 2022-08-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-28 | 2022-08-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-07-28 | 2022-08-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-07-28 | 2022-08-23 | 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 | 2022-07-28 | 2022-08-23 | N |
| Provide or obtain dental services for each resident. | Health | 2022-07-28 | 2022-08-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-28 | 2022-08-23 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2022-07-28 | 2022-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-28 | 2022-08-23 | 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 | 2022-07-28 | 2022-08-23 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-20 | 2022-08-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-20 | 2022-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-20 | 2022-08-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-20 | 2022-08-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-20 | 2022-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-20 | 2022-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-20 | 2022-08-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-31 | 2022-05-03 | Y |
| 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 | 2022-02-04 | 2022-05-03 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-02-04 | 2022-05-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-04 | 2022-05-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-29 | 2021-12-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-30 | 2021-10-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-30 | 2021-10-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-01 | 2021-09-17 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-06-25 | 2021-07-15 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-06-25 | 2021-07-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-25 | 2021-07-15 | 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 | 2021-06-25 | 2021-07-15 | Y |
| 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 | 2021-06-25 | 2021-07-15 | Y |
| 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 | 2021-06-25 | 2021-07-15 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-06-25 | 2021-07-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-25 | 2021-07-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-22 | 2021-07-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-22 | 2021-07-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-22 | 2021-07-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-06-27 | 2019-07-30 | 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 | 2019-06-27 | 2019-07-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-27 | 2019-07-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-27 | 2019-07-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-27 | 2019-07-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-27 | 2019-07-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-06-27 | 2019-07-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-27 | 2019-07-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-27 | 2019-07-30 | 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 | 2019-06-27 | 2019-07-30 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-06-27 | 2019-07-30 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2018-03-22 | 2018-04-19 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2018-03-22 | 2018-04-19 | 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 | 2018-03-22 | 2018-04-19 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-03-22 | 2018-04-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-22 | 2018-04-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-22 | 2018-04-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-22 | 2018-04-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-03-22 | 2018-04-19 | 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 | 2018-03-22 | 2018-04-19 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-03-22 | 2018-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-22 | 2018-04-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-22 | 2018-04-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-03-22 | 2018-04-19 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-03-22 | 2018-04-19 | 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 | 2018-03-22 | 2018-04-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-03-22 | 2018-04-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-22 | 2018-04-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-03-22 | 2018-04-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-03-22 | 2018-04-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-22 | 2018-04-19 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-03-22 | 2018-04-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-22 | 2018-04-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-22 | 2018-04-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-22 | 2018-04-19 | N |
