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Deficiency Records for Friendship Health and Rehab Center - South
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.
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? |
|---|---|---|---|---|
| Install an approved automatic sprinkler system. | Fire Safety | 2024-05-01 | 2024-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-01 | 2024-06-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-25 | 2024-06-20 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-04-25 | 2024-06-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-04-25 | 2024-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-25 | 2024-06-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-25 | 2024-06-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-04-25 | 2024-06-20 | 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 | 2024-04-25 | 2024-06-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-25 | 2024-06-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-25 | 2024-06-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-25 | 2024-06-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-04-25 | 2024-06-20 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-04-25 | 2024-06-20 | N |
| 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 |
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