Friendship Haven, Inc

In the surveyor’s words

From the most serious findings on record at Friendship Haven, Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 24, 2021

  Based on observation, record and facility policy review and staff interviews, the facility failed to ensure each resident received adequate supervision to prevent elopement for 1 of 10 residents (Resident #1) identified by the facility at high risk for elopement. Resident #1, who was cognitively impaired, exited the facility unsupervised and without staff knowledge for 46 minutes in his wheelchair with weather temperature 88 degrees. The facility reported a census of 111 residents. 1. Resident #1 had an Admission Minimum Data Set (MDS) assessment dated [DATE], that documented diagnoses that included: hypertension, arthritis, anxiety, [CONDITION(S)] and [CONDITION(S)]. […]

• Actual harm, isolatedF689May 18, 2023

  Based on clinical record review, interviews, and facility policy review the facility failed to ensure one (1) of four (4) residents received adequate supervision to protect against hazards in the environment (Resident #3). The facility's staff failed to implement safety measures to prevent a fall by not locking the resident's wheelchair brakes and not using a gait belt when transferring a resident. The record review and staff interviews revealed that Resident #3 required assistance with the use of a gait belt for transfers and ambulation. On 1/30/23, one staff member (Staff A, Certified Nurse Aide CNA) assisted Resident #3 to transfer without a gait belt. As Resident #3 went to sit in the wheelchair, it had one unlocked brake causing the wheelchair to move. […]

• No harm, potential for more than minimal, patternF880Apr 26, 2021

  Based on observation, staff interviews, and record review, the facility failed to ensure appropriate infection control as indicated by the Centers for Disease Control (CDC) regarding the use of personal protective equipment for four staff members observed. The facility reported a census of 103 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #96 showed the resident with a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. […]

• No harm, potential for more than minimal, isolatedF689Aug 20, 2026

  Based on record review, observation, policy review and staff interviews the facility failed to ensure staff appropriately and safely transported a resident in a wheelchair with the resident's feet on the wheelchair foot pedals for two of seven residents that required use of a wheelchair for transport (Resident #26 and Resident #109). The facility reported a census of 110 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had diagnoses of dementia and muscle weakness. The resident had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderately impaired cognition. The MDS indicated the resident used a wheelchair and required partial to moderate assistance for wheeling at least 150 feet in a corridor or similar space. […]

• No harm, potential for more than minimal, isolatedF759Aug 20, 2026

  Based on record review, observations, staff interviews, policy review and manufacturer's instructions the facility failed to assure a medication error rate of less than 5%. During observations of medication administration, the facility had 2 errors out of 31 opportunities resulting in an error rate of 6.45 % (Residents #113 and #124). The facility reported a census of 110 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #113 had diagnosis of Type 2 diabetes (a chronic condition where the body resists or cannot use insulin well or does not make enough insulin). […]