Friendship Manor

Based on interview and record review the facility failed to follow their policy and use two staff members to perform a mechanical lift transfer for one of three Residents (R1) reviewed for Falls in a sample of six.Findings include:The Facility Lifting Machine, Using a Mechanical Lift Policy, revised 7/2017, documents: to establish general principles of safe lifting using a mechanical lifting device; at least two people are needed to safely move a Resident with a mechanical lift; and before the Resident is lifted, double check the security of the sling attachment; check the stability of the straps.The Facility Safe Lifting and Movement of Residents Policy, revised 9/17/25, documents: to protect the safety and well-being of staff and Residents to promote quality care, this Facility uses appropriate techniques and devices to lift and move Residents; Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of Residents; staff responsible for direct Resident care will be trained in the use of mechanical…

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, interview and record review, the facility failed to implement Enhanced Barrier Precautions throughout the facility to protect vulnerable residents and prevent the spread of multi-drug resistant organisms (MDROs). This failure has the potential to affect all 73 residents residing in the facility. Findings include: The facility's Enhanced Barrier Precautions policy, dated 8/2022, documents Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include Dressing, Bathing/Showering, Transferring, Providing Hygiene, Changing Linens, Changing briefs or Assisting with toileting, Device care or use (Central Line, Urinary Catheter, Feeding Tube, Tracheostomy/Ventilator), and Wound Care (any skin opening requiring a dressing). This same policy also documents EBPs are indicated (when contact…

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, interview and record review the facility failed to store food items in accordance with professional standards for food service safety in the facility refrigerator by not discarding outdated food items. This failure has the potential to affect all 79 Residents residing in the Facility. Findings include: Facility Census and Conditions Report, dated 7/16/23, documents 79 Residents residing in the Facility. Facility Food Storage Policy and Procedure Manual, dated 3/2023, documents: sufficient storage facilities will be provided to keep foods safe, wholesome and appetizing; food will be stored by methods designed to prevent contamination or cross contamination; food should be dated as it is placed on the shelves if required by state regulation; leftover food must be used within three days or discarded; and all foods should be covered, labeled and dated and routinely monitored to assure foods (including leftovers) will be consumed by their safe use by dates or discarded. On 07/16/23, at 6:35 am, the Facility refrigerator located closest to the food preparation area…

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, interview and record review the facility failed to perform catheter care in a clean manner for one resident (R62) of three residents reviewed for catheters in a total sample of 38. This failure resulted in R62 having repeated Urinary Tract Infections. Findings Include: The Facility's undated Catheter Care Policy documents the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. General Guidelines: follow aseptic technique. The Center for Disease Control website documents Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations. Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient; Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices; Before moving from work on a soiled body site to a clean body site on the same patient; After touching a patient or the patient ' s immediate…

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, interview and record review the facility failed to identify an appropriate indication for use of an antipsychotic medication and failed to identify specific target behaviors in the care plan for one residents (R178) with Dementia diagnosis of five residents reviewed for unnecessary medications in the sample of 38. Findings include: Facility Policy/Psychopharmacological Medication Use (undated) documents: Residents will receive psychotropic medication when necessary to treat specific conditions for which they are indicated and effective. Policy does not include obtaining consent to administer psychotropic medications, indications or expressions of distress or potential adverse consequences. On 7/18/23 at 2:45pm V9 (Social Service Director/SSD) acknowledged the facility's Psychotropic policy is very outdated and does not cover some of the necessary elements of psychotropic medication management. 1) Current Physician's Orders indicate R178 is [AGE] years old, was admitted on [DATE] with…

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 interview and record review, the facility failed to COVID-19 test unvaccinated staff two times a week. This has the potential to affect all 71 residents residing in the facility. Findings include: The facility's Plan for Staff and Residents Who Aren't Vaccinated or Won't Test, no date available, documents, Staff who aren't vaccinated or aren't up to date must file for an exemption; Exemptions are tracked through the HR (Human Resources) department. Staff who aren't vaccinated or aren't up to date must test according to mandated schedules. The facility's COVID-19 Daily Briefing, dated 5/2/22, documents, Next testing round: Monday & Thursday 1:00-3:00 p.m.; testing frequency two times this week for all not up to date staff. The facility's Fully Unvaccinated staff log, provided on 5/5/22 by V4 (Assistant Administrator), documents that V8 and V19 (Both Certified Nursing Assistants) are not vaccinated due to religious exemptions. According to the Centers for Disease Control and Prevention COVID-19 Data Tracker, Community Transmission Level, the Community Transmission Level in…

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 interview and record review, the facility failed to ensure three allegations of abuse were immediately reported to the Administrator for three of five residents (R12, R17 and R39) reviewed for abuse in the sample of 39. Findings include: The facility's Abuse Investigation and Reporting policy (revised 7/2017) documents the following: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. This policy also documents, Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The resident's representative (sponsor) of record; Adult protective…

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 interview and record review, the facility failed to ensure Care Plans were revised following a physical altercation between residents for two of five residents (R21 and R65) reviewed for abuse in the sample of 39. Findings include: The facility's Incident Report Investigation (dated 03/31/22) documents R65 cursed at R21, punched R21 in the leg, and ran over R21's feet when propelling her wheelchair attempting to exit the dining room. R21 and the R65 were immediately separated, R65 was placed on 15-minute checks and the new intervention to provide R65 with a walker to ambulate to and from the dining room during meals for easier entrance and exit was implemented. R21's and R65's current Care Plans have no documentation of the 03/31/22 incident that occurred in the dining room. On 05/04/22 at 1:50 PM, V10 (Social Service Director) stated that R65's and R21's Care Plans were not revised to note the physical altercation that occurred on 03/31/22.

Based on observation, interview, and record review, the facility failed to stage and assess a pressure ulcer when it was discovered, perform incontinence care prior to wound care, and perform hand hygiene during pressure ulcer care for one of two residents (R59) reviewed for pressure ulcers in the sample of 39. Findings include: The facility's Pressure Ulcers/Skin Breakdown policy, dated 4/2018, documents, The nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. The facility's Handwashing/Hand Hygiene policy, no date available, documents, This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: All nursing staff shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: After…

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 interview and record review, the facility failed to use a gait belt and provide supervision while transferring a dependent resident for one of two residents (R46) reviewed for falls in the sample of 39. Findings include: The facility's (undated) Transferring with use of Gait Belt policy, documents, Purpose: To safely assist in resident transfer while minimizing the chance of injury to staff or resident. R46's Profile Face Sheet documents R46 was admitted to the facility on [DATE] with diagnoses of Unsteadiness on Feet, Muscle Weakness (generalized), Unspecified Dementia Without Behavioral Disturbance and History of Falling. R46's Minimum Data Set assessment, dated 3/21/22, documents R46 requires extensive assistance of one person for walking and toileting. R46's Nursing admission Evaluation, dated 9/16/21, documents Fall Risk: (R46's has/had a) Fall in the last 30 days, Impaired balance, Cardiovascular drug (prescription medication) use, Unsteady gait (walking), Impaired safety awareness. R46's Post…

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 interview and record review, the facility failed to ensure all facility staff have been fully vaccinated for COVID-19, unvaccinated staff have requested an exemption, and failed to track and document all facility contract staff for COVID-19 vaccination status. This has the potential to affect all 71 residents residing in the facility. Findings include: The facility's Plan for Staff and Residents Who Aren't Vaccinated or Won't Test, no date available, documents, Staff who aren't vaccinated or aren't up to date must file for an exemption; Exemptions are tracked through the HR (Human Resources) department. Staff who aren't vaccinated or aren't up to date must test according to mandated schedules. The facility's Visitor/Vendor Access Information, provided on 5/2/22 by V2 (Director of Nursing), documents, Vendors who are providing direct care (touching/being directly close to residents) are not allowed to come in unless they are on the list below or provide a copy of their up to date COVID-19 vaccination card or provide an up to date card on the spot (a copy must be taken for…

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.