Friendship Home Association

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Electronic Health Records (EHR) review, observation, document review, Medication Administration Record - Treatment Administration Record (MAR-TAR), staff interview and family interview the facility failed to notify the resident's representative / family / Power of Attorney (POA) for a new physicians order and change in condition when a wander guard was placed on the resident for 2 of 3 residents (Residents #2 and #3) reviewed. The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 2 indicating severe cognitive impairment. The MDS also documented Resident #2 had diagnoses of dementia with psychotic disturbances and Alzheimer's disease with late onset. Review of Resident #2's undated EHR titled, Clinical Resident Profile documented Resident #2 had a POA.Observation on 9/3/25 of Resident #2 with a wander guard placed on the right lower leg.Review of Resident #2's MDS dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical Medication Administration Records - Treatment Administration Records (MAR-TAR), Electronic Health Records (EHR) review, document review, family interview, staff interview, and policy review the facility failed to provide adequate nursing supervision when a resident left the facility from a Chronic Confusion or Dementia Illness (CCDI) unit and walked outside into the back yard of a neighboring resident unknown to the staff for 1 of 3 residents (Resident #1) reviewed. The facility reported a census of 42. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS documented utilization of a wander guard and wandering behavior had occurred 1-3 days reviewed for the MDS.Review of Resident #1's EHR dated 8/4/25 at 7:15 PM by Staff A, Licensed Practical Nurse (LPN) titled, Progress Notes documented that Resident #1 was found outside across the back parking lot on a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on personnel document review, facility document review, staff interview, and policy review the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment. The facility reported a census of 40 residents. Findings include: Review of background check for Staff E revealed the background check was completed 2/13/24. Review of an untitled document with staff phone number and hire dates provided by the facility revealed a hire date for Staff E of 11/30/23. During an interview 7/30/24 at 11:46 AM with the Administrator revealed that Staff E had worked at the facility prior to her being rehired 11/30/23. The Administrator further revealed she thinks that the background check got missed upon rehire and was completed again 2/13/24. The Administrator then revealed that her expectation would be for background checks to be completed prior to working at the facility. Review of a facility provided policy with a subject of background checks dated 1/29/21 documented: a. Background checks will be completed on all new hires per state…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility document review, observations, staff interview and policy review the facility failed to ensure that residents were served the food as listed on the menu, and failed to accurately measure the pureed food items for 3 of 3 residents reviewed. The facility reported a census of 40 residents. Findings include: According to the Week at a Glance Menu for Week 5; the lunch meal on 7/30/24 included ham loaf with pineapple sauce, potato, broccoli, bread/margarine, ice cream and milk. The pureed meal would include pureed bread with margarine. On 7/30/24 at 10:00 AM Staff A, Dietary Aide/Cook, prepared the broccoli for 3 residents that required pureed foods. She used a small hand-held mixer and said that she had added water earlier to aide in the pureeing process. After getting the vegetable to the desired consistency, she put it in the dish, covered it with tin foil and put it in the oven. Staff A then got the ham loaf out of the oven and said she had 6 mechanical soft and 3 pureed to prepare. She dished…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews and policy review the facility failed to ensure that open containers of food had been dated. Staff failed to provide safe hand hygiene procedures during meal service. The facility reported a census of 40 residents. Findings include: In an observation of the walk-in refrigerator with the Dietary Manager (DM) on 7/29/24 at 9:45 AM, it was discovered that there were three large bags of shredded cheese and a bag of shredded lettuce that had been opened and half-used. The bags did not have a date written on them to indicate when they were opened. At the front of the walk-in, there was a tray cart on wheels that contained a tray of individual cups of pudding, uncovered and undated. On the top shelf, there was an opened bag of cubed cheese that had been opened, with no open date. As the DM lifted the bag, it was revealed to have some mold spots on a couple cheese cubes at on the bottom of the bag. The DM said that she expected staff to enter the open date on the bags and to pay attention to outdates. In the freezer, an open bag of what looked to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical document review, staff interview, and policy review the facility failed to have the correct documentation of residents choice related to advanced directives for 1 of 5 residents (Resident #27) reviewed. The facility reported a census of 40 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #27 dated [DATE] revealed Resident #27 was admitted to the facility [DATE]. Review of a document titled, Iowa Physician Orders for Scope of Treatment (IPOST) dated [DATE] revealed there was a selection for Cardiopulmonary Resuscitation (CPR). This document further revealed the IPOST was signed by the Physician and Resident #27 ' s representative. Review of the Electronic Health Records (EHR) on [DATE] revealed a document titled, Clinical Physician Orders that revealed an order for Full Code status with a start date of [DATE]. Review of Resident #27 ' s Care Plan with a revision date of [DATE] revealed that Resident 27 ' s family requested DNR status. During an interview [DATE] at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 43. Findings include: During a continuous observation on 11/7/23 beginning at 11:15 AM, Staff A, Dietary [NAME] (DC), obtained the temperatures of 10 menu items prior to serving residents lunch. The temperature of the pureed coleslaw measured 50.2° degrees Fahrenheit (deg F). Staff A covered the pureed coleslaw and placed it in the refrigerator. All other menu items' temperatures were within required range. At 11:30 AM, Staff A removed the pureed coleslaw from the refrigerator and check the temperature which measured 49.2° deg F. She stated it would just have to be written up. It was served to the resident at that temperature. At 11:55 AM, Staff A took the temperatures of the remaining menu items. Observed 3 menu items outside of the acceptable holding temperature: a. French Fries - post-serving temperature of 131.1° deg F b. Carrots - post-serving temperature of 107.4° deg F c. Coleslaw -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, document review, staff interview, and policy review the facility failed to store food and follow proper sanitation to prevent cross contamination and the spread of illness in accordance with professional standards. The facility reported a census of 43 residents. Findings include: 1. An initial kitchen tour on 11/6/23 at 10:15 AM - 10:45 AM revealed: a. Walk in refrigerator had items open without open dates that included a bag of toffee bites, a bag of sliced American cheese, a bag of shredded parmesan cheese, a bag of cheddar cheese, a bag of mixed vegetables, a bag of carrots, a bag of lettuce, and a 20 oz. bottle of soda pop. b. Dry storage had items open without open dates that included a 25 lbs. bag of rice, 1 gallon of syrup, a bag of croutons, a bag of crispy onions, 2 bags of dry noodles, a bag of spaghetti noodles, and a bag of crushed crackers. c. Walk in freezer had items open without open dates that included a bag of frozen noodles, a bag of mixed vegetables, a bag of corn, a bag of raspberries, a bag of diced green peppers, a bag of carrots, and a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCIES RELATE TO THE IOWA ADMINISTRATIVE CODE (IAC) CHAPTER 58. VA State Rule 58.12(1)l Within 30 days of a resident's admission to a health care facility receiving reimbursement through the medical assistance program under Iowa Code chapter 249 A, the facility shall ask the resident or the resident's personal representative whether the resident is a veteran and shall document the response. If the facility determines that the resident is a veteran, the facility shall report the resident's name along with the names of the resident's spouse and any dependent children, as well as the name of the contact person for this information, to the Iowa department of veteran's affairs. Where appropriate, the facility first shall seek reimbursement from the identified payor source before seeking reimbursement from the medical assistance program established under Iowa Code chapter 249A. This REQUIREMENT is not met as evidenced by: Based on document review, and staff interview, the facility failed to inquire…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to ensure the required members attended the Quality Assessment and Assurance committee (QAA). The required members included: 1. The Nursing Home Administer (NHA) or representative; 2. Director of Nursing (DON); 3. The Medical Director (MD) or representative; 4. The Infection Preventionist; and 5. two other members of the facility's staff present on a minimum of a quarterly basis. The facility reported a census of 43. Findings include: A facility document titled QAA Committee Minutes, dated 12/6/22 for the 4th quarter lacked attendance signatures for the Infection Preventionist. A facility document titled QAA Committee Minutes, dated 3/2/23 for the quarter December 2022 - February 2023 lacked attendance signatures for the Infection Preventionist. A facility document titled QAA Committee Minutes, dated 5/18/23 for quarter March 2023 - May 18, 2023 lacked attendance signatures for the Infection Preventionist and two (2) other staff members. A facility document titled QAA Committee Minutes, dated 8/10/23 for quarter 5/18/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing suprapubic catheter cares for 1 of 2 residents (Resident #26). Findings include: Resident #26's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Resident #26 had an indwelling catheter. The MDS included diagnoses of obstructive uropathy, diabetes mellitus, and benign prostatic hyperplasia with lower urinary tract symptoms. During a continuous observation 11/8/23 at 7:15 AM observed Staff D, Certified Nurse's Aide (CNA), and Staff E, CNA, perform catheter care on Resident #26. During Resident #26's catheter care, Staff D got a new unpackaged catheter drainage bag, placed it on the bed sheet without a barrier, immediately picked it up, and asked Staff E to obtain a new barrier. Staff E then placed a new barrier down and they placed the previously new…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.