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Deficiency Records for Friendship Health Center
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.
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? |
---|---|---|---|---|
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-07-30 | 2024-09-17 | Y |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-30 | 2024-09-17 | Y |
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 | 2024-07-30 | 2024-09-17 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-30 | 2024-09-17 | Y |
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 |
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