Deficiency Records for Friendship Health and Rehab Center - South
Updated as of April 01, 2024
A list of the most recent deficiencies for Friendship Health and Rehab Center - South. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-21 | 2023-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-21 | 2023-03-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-21 | 2023-03-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-21 | 2023-03-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-21 | 2022-12-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-21 | 2022-12-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-21 | 2022-12-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-21 | 2022-12-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-21 | 2022-12-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-21 | 2022-12-05 | 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 | 2022-10-13 | 2022-11-15 | 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 | 2022-10-13 | 2022-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-13 | 2022-11-15 | 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 | 2019-12-20 | 2020-01-23 | 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 | 2019-12-20 | 2020-01-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-20 | 2020-01-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-20 | 2020-01-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-12-20 | 2020-01-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-05 | 2019-12-13 | 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 | 2019-12-05 | 2019-12-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-02 | 2018-09-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-08-02 | 2018-09-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-08-02 | 2018-09-16 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2018-08-02 | 2018-09-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-02 | 2018-09-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-08-02 | 2018-09-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-02 | 2018-09-16 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-08-02 | 2018-09-16 | 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 | 2018-08-02 | 2018-09-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-08-02 | 2018-09-16 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-08-02 | 2018-09-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-08-02 | 2018-09-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-02 | 2018-09-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-02 | 2018-09-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-02 | 2018-09-16 | 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 | 2018-08-02 | 2018-09-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-08-02 | 2018-09-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-08-02 | 2018-09-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-02 | 2018-09-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-02 | 2018-09-16 | 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 | 2018-08-02 | 2018-09-16 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2018-08-02 | 2018-09-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-02 | 2018-09-16 | N |
| Use approved construction type or materials. | Fire Safety | 2018-08-20 | 2018-09-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-20 | 2018-09-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-20 | 2018-09-12 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-08-20 | 2018-09-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-20 | 2018-09-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-08-20 | 2018-09-12 | N |
