Friendship Haven Healthcare And Rehabilitation Cen

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) of enteral feeding for 1 (Resident #56) of 8 residents reviewed for enteral nutrition.The facility failed to ensure LVN A used the appropriate procedure for checking placement and administering flushes and medication during medication administration. The facility failed to ensure LVN A did not use air to check for placement. The facility failed to ensure LVN A used the appropriate amount of water to dilute medication and to flush in between medication administration.These failures could have placed residents with a gastrostomy tube at risk for complications, aspiration, and pneumonia.Findings included:Record review of Resident #56's face sheet dated 01/19/2026 revealed an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included: cerebral infarction (a type of…

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 ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 12%, based on 3 errors out of 25 opportunities, which involved 1 (Resident #56) of 5 residents reviewed for medication errors.The facility failed to ensure/ prevent when LVN A left a substantial amount of medication residue for Amlodipine 5mg give 1 tab via G-tube two times a day, Coreg Oral Tablet 6.25 MG (Carvedilol) give 1 tablet via G-Tube two times a day, and Lansoprazole 30mg give 1 tablet via G-Tube two times a day in the medication cups after medications were administered through a g-tube to Resident #56. These failures could have placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.Findings included:Record review of Resident #56's face sheet dated 01/19/2026, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included:…

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 permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 4 residents (CR #2) reviewed for discharge requirements. The facility failed to ensure CR #2 was readmitted to the facility, after being sent to the hospital for evaluations due to change in condition. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services.A record review of CR #2's electronic face sheet revealed reflected an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. CR #2's diagnosis included Dementia, type 2 diabetes mellitus, history of falling, peripheral vascular disease (disorder of the blood vessels),…

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 interviews and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 3 residents reviewed for PASRR services.The facility failed to submit Resident #1's NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health. Record review of Resident #1's face sheet dated 09/03/25 revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included- Profound intellectual disabilities, major depressive disorder, anxiety disorder, bilateral primary osteoarthritis of knee, (tissue wears down) prediabetes, gastric ulcer, anemia (Low Blood count), age-related osteoporosis, and end stage renal diseaseRecord review of Resident #1's PASRR evaluation dated 12/27/25 indicated Resident #1 was…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 9 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control practices. 1. The facility failed to ensure ADON A and the Restorative Aide applied enhanced barrier precautions while transferring Resident # 1 from her wheelchair to her bed. 2. The facility failed to ensure that CNA J and CNA G sanitized their hands when providing incontinent care to Resident #2 and Resident #3. These failures could place residents at risk of cross-contamination and infections leading to illness. Findings included: Record review of Resident #1's undated face sheet indicated the resident was a 92-year- old female who was readmitted to the facility on [DATE] with diagnoses of dementia (a group of thinking…

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 ensure residents received meals at regular times comparable to normal mealtimes in the community or in accordance with resident needs and preferences for three of three days (11/04/24, 11/05/24, and 11/06/24) reviewed for frequency of meals. -The facility failed to ensure residents received meals at regularly scheduled times for breakfast and lunch on 11/04/24, breakfast and lunch on 11/05/24, and breakfast on 11/06/24. This failure could place residents who eat from the facility's kitchen, at risk of loss of appetite, weight loss, increased hunger, thirst, frustration, and decreased feelings of self-worth. Findings included: Observation and interview with the Dietary Manager on 11/04/24 at 8:25 AM, revealed the posted mealtime was 7:30 AM for breakfast,: 11:30 AM for lunch, and 4:30 PM for dinner. During an interview with the dietary Manager, she said mealtime were 7:30 AM for breakfast, 11:30 AM for Lunch, and 4:30 PM for dinner. Observation and interviews on 11/04/24 at 9:00AM revealed no breakfast trays…

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 provide a safe, sanitary, and homelike environment for 2 of the 5 residents observed for environment. The facility failed to ensure Resident # 1 and Resident #2 room was sanitary and homelike. This failure could place residents at risk of not receiving a safe, clean, comfortable, and homelike environment to attain or maintain their highest practicable physical, mental, and psychosocial wellbeing. The findings included: Based on observation on 9/4/24 at 8:45am Resident #1 and Resident #2 room revealed it was not clean. There was a bag under the bed, tissue paper on the floor and residue under both beds, the floor was sticky, the walls behind each bed revealed paint removed from the wall headboard leaning forward on Resident's #1 bed, floor mate(sponage type mate used to prevent injuries from falls) for Resident's #1 was dirty and stained. Record Review of Resident #1's history and physical dated 1/5/24 reflected a [AGE] year-old female…

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, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that 4 Frozen rolls of 10 lb. ground beef in a pan being thawed in the sink. This failure could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 08/29/23 at 8:30 AM revealed 4- 10 lb. frozen ground beef in a pan being thawed in the sink faucet water running with a temperature of 91 degrees Fahrenheit. Ground beef had an internal temperature of 73.8 degrees Fahrenheit indicating that the temperature is in the Danger Zone (41 degrees Fahrenheit to 135 degrees Fahrenheit). Interview with the Food Service Manager on 08/29/23 at 8:35 AM he stated that ground beef temperature of 73.8 degrees Fahrenheit indicates that the frozen beef was inappropriately being thawed. He also stated that he is responsible for training staff on thawing requirements…

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 ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 4 of 8 residents (Resident #91, Resident #11, Resident #50 and, Resident #4) reviewed for ADLs. 1. The facility failed to ensure Resident #91 was provided shower or bed bath for two weeks which caused the resident's skin to be dry and flaky. 2. The facility failed to ensure Resident # 11 was provided grooming (shaving and nail care). 3. The facility failed to ensure Resident # 50 was provided grooming (nail care). 4. The facility failed to ensure Resident #4 was provided grooming (shaving) These failures could place residents at risk for discomfort, and dignity issues. Findings included: Resident #91 Record review of Resident #91 face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her…

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 immediately inform the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #91) reviewed for notification of changes in that: The facility failed to notify Resident #91's physician when Resident #91 presented with skin tear under her skin fold before the abdomen, rashes on the abdomial folds and peri - area. This deficient practice could place residents at risk of not having their physician informed when there was a change in condition resulting in a delay in medical intervention and decline in health. Findings include: Resident #91 Record review of Resident #91 face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses were diabetes mellitus (elevated levels of blood glucose), Morbid obesity (weight is more than 80 to 100 pounds above ideal body weight),…

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 observations, interviews and record review, the facility failed to ensure resident was free from significant medication errors for Resident #109 reviewed for significant medication errors. -The facility failed to ensure that Resident #109's anticonvulsant medications was administered as ordered by his physician. This failure could affect residents who received medication placing them at risk of not receiving the therapeutic effect of the mediations and could result in declining health status. Findings included: Record review of Resident #109 's admission face sheet dated 09/01/2023 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and was initially admitted on [DATE]. Her diagnoses included Seizure disorder or Epilepsy, type 2 diabetes mellitus without complications, hypertensive heart disease without heart failure, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety Record review of Resident…

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 dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 08-29-23 at 8:50 am revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster ¾ full of garbage and the top lid was missing Interview on 08-29-23 at 8:50 am, the Food Service Director stated that the dumpster lids always must be closed to keep vermin, pests and insects out of the dumpster and from entering the facility. Record review of facility policy and procedure Dispose of Garbage and Refuse dated 8/2017 revealed all garbage and refuse will be collected and disposed of in a safe and efficient manner. Procedures read in part .that the Food Service Director will ensure that appropriate lids are closed and provided for the dumpster.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 6 residents (Resident #91) observed for accuracy of medical records in that: The facility failed to discontinue Resident #91's skin tear and rashes on progress notes and weekly skin assessment. This deficient practice could place residents at risk for errors in care and treatment. Findings include: Resident #91 Record review of Resident #91 face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses were diabetes mellitus (elevated levels of blood glucose), Morbid obesity (weight is more than 80 to 100 pounds above ideal body weight), atherosclerotic heart disease (thickening or hardening of the arteries), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of…

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.