A list of the most recent deficiencies for Friendship Health Center. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-18 | 2023-10-24 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-09-18 | 2023-10-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-18 | 2023-10-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-18 | 2023-10-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-18 | 2023-10-24 | 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 | 2023-09-18 | 2023-10-24 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-09-18 | 2023-10-24 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-30 | 2023-07-24 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-30 | 2023-07-24 | 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 | 2023-06-30 | 2023-07-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-30 | 2023-07-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-30 | 2023-07-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-30 | 2023-07-24 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-06-30 | 2023-07-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-30 | 2023-07-24 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-30 | 2023-07-24 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-06-30 | 2023-07-24 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-30 | 2023-07-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-30 | 2023-07-24 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-06 | 2023-07-18 | 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 | 2023-07-06 | 2023-07-18 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-07-06 | 2023-07-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-06 | 2023-07-18 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-07-06 | 2023-07-18 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-02-14 | 2023-04-04 | 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 | 2022-05-04 | 2022-06-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-04 | 2022-06-23 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-05-04 | 2022-06-23 | N |
| Respond appropriately to all alleged violations. | Health | 2022-05-04 | 2022-06-23 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-04 | 2022-06-23 | Y |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-04-27 | 2022-06-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-27 | 2022-06-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-27 | 2022-06-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-27 | 2022-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-04 | 2022-06-17 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-16 | 2019-11-05 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-09-16 | 2019-11-05 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2019-09-16 | 2019-11-05 | N |
| 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 | 2019-09-16 | 2019-11-05 | 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 | 2019-09-16 | 2019-11-05 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-09-16 | 2019-11-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-16 | 2019-11-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-16 | 2019-11-05 | 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 | 2019-09-16 | 2019-11-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-16 | 2019-11-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-16 | 2019-11-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-16 | 2019-11-05 | 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 | 2019-09-16 | 2019-11-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-16 | 2019-11-05 | 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 | 2019-09-16 | 2019-11-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-16 | 2019-11-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-16 | 2019-11-05 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-09-16 | 2019-11-05 | 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 | 2019-09-16 | 2019-11-05 | 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 | 2019-09-16 | 2019-11-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-09-16 | 2019-11-05 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-09-16 | 2019-11-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-16 | 2019-11-05 | 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 | 2019-09-16 | 2019-11-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-16 | 2019-11-05 | 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 | 2019-09-16 | 2019-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-16 | 2019-11-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-16 | 2019-11-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-10 | 2019-11-05 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-09-10 | 2019-11-05 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-10 | 2019-11-05 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-09-10 | 2019-11-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-09-10 | 2019-11-05 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-09-10 | 2019-11-05 | 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 | 2019-09-10 | 2019-11-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-10 | 2019-11-05 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-09-10 | 2019-11-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-10 | 2019-11-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-09-10 | 2019-11-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-10 | 2019-11-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-16 | 2019-10-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-16 | 2019-10-07 | N |
