Deficiency Records for Friendship Health Center
Updated as of September 01, 2020
This is not the most recent data for Friendship Health Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 other general requirements that are deficient. | 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 |
| 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 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 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 |
| 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-16 | 2019-11-05 | 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 | 2019-09-16 | 2019-11-05 | Y |
| 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 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-09-16 | 2019-11-05 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-09-16 | 2019-11-05 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-16 | 2019-11-05 | Y |
| 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 | Y |
| 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 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-16 | 2019-10-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-16 | 2019-10-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-01-24 | 2019-03-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-24 | 2019-03-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-24 | 2019-03-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-24 | 2019-03-15 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2018-06-18 | 2018-10-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-06-18 | 2018-10-02 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-06-18 | 2018-10-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-29 | 2018-09-12 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Develop a communication plan. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-06-18 | 2018-08-13 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-06-26 | 2018-08-13 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2018-06-26 | 2018-08-13 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-06-26 | 2018-08-13 | 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 | 2018-06-26 | 2018-08-13 | 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 | 2018-06-26 | 2018-08-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-06-26 | 2018-08-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-06-26 | 2018-08-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-26 | 2018-08-13 | 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 | 2018-06-26 | 2018-08-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-06-26 | 2018-08-13 | 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 | 2018-06-26 | 2018-08-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-06-26 | 2018-08-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-06-26 | 2018-08-13 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2018-06-26 | 2018-08-13 | 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 | 2018-06-26 | 2018-08-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-06-26 | 2018-08-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-03-16 | 2018-04-20 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-03-16 | 2018-04-13 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2018-03-16 | 2018-04-13 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-04-26 | 2017-06-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-04-26 | 2017-06-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-04-26 | 2017-06-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-04-26 | 2017-06-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-04-26 | 2017-06-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-04-26 | 2017-06-09 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-04-21 | 2017-06-09 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-04-21 | 2017-06-09 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-04-21 | 2017-06-09 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-21 | 2017-06-09 | 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 | 2017-04-26 | 2017-06-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2017-04-26 | 2017-05-10 | N |
