Friendship Health and Rehab

In the surveyor’s words

From the most serious findings on record at Friendship Health and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 16, 2023

  Based on observations, staff interviews, and review of facility policies titled, Pot and Pan Washing and Sanitation, Dishwashing, Food storage and Inventory, Food temperatures, and Personal Hygiene, the facility failed to ensure pans were stored dry to prevent bacterial growth; failed to store food items off the floor in the dry storage area and walk-in refrigerator; failed to ensure resident nourishment refrigerator food items were properly labeled and dated; failed to ensure all food items served on the steam table were held above 135 degrees Fahrenheit; and failed to ensure male dietary staff completely covered facial hair. These deficient practices affected all 39 residents consuming an oral diet. Findings include: 1. […]

• No harm, potential for more than minimal, patternF758Apr 16, 2023

  Based on record review, staff interview, and review of the facility's policies titled, Automatic Stop Orders, and Medication Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for four of four residents (R) (R#13, R#9, R#14, R#21) reviewed for unnecessary medications. This failure had the potential for medication interaction, adverse reactions, respiratory depression, falls, constipation, and increased anxiety. Findings include: Review of the facility's policy titled, Automatic Stop Orders, number IB3, effective date 4/1/2016, revealed the policy did not address a 14-day stop date for psychotropic medications. […]

• No harm, potential for more than minimal, isolatedF880Apr 24, 2025

  Based on observations, staff interviews, and review of the facility's policies Handwashing/Hand Hygiene, and Medication Administration-General Guidelines, the facility failed to perform proper hand hygiene practices while observing two out of two Licensed Practical Nurses (LPN) (LPN AA and LPN BB) during medication administration. This deficient practices had the potential to increase the risk of infection transmission and compromise the health and safety of residents. The facility census was 55 residents. Findings include: Review of the facility's policy Handwashing/Hand Hygiene, dated February 2021 under the Policy Statement revealed, 2. […]

• No harm, potential for more than minimal, isolatedF695Apr 16, 2023

  Based on observation, staff interviews, record review, and review of the facility's policy titled, Sanitation and Infection Control Oxygen Concentrator and Humidifier, the facility failed to ensure the filter on an oxygen concentrator for one of four residents (R) (R#20) receiving oxygen therapy was changed per physician's order. This failure had the potential to compromise R#20's access to the required level of oxygen. Findings include: Review of the facility's policy titled, Sanitation and Infection Control Oxygen Concentrator and Humidifier, revised September 2020, revealed oxygen filters were to be cleaned weekly and as needed and recorded on the Treatment Administration Record (TAR). […]

• No harm, potential for more than minimal, isolatedF695Jan 6, 2022

  Based on observations, record review, staff interviews and review of the policy titled Sanitation and Infection Control Oxygen Concentrator and Humidifier, the facility failed to ensure humidification was provided for one resident (R#10) receiving two liters of Oxygen therapy. The sample size was 27 residents. Findings include: Review of the facility policy titled Sanitation and Infection Control Oxygen Concentrator and Humidifier revealed the purpose is to ensure that oxygen concentrators, humidifier bottles, and nebulizer setups remain clean, revised 9/2020. General information is to follow the schedule and intervals specified in this procedure unless State specific requirements specify more frequent time frames. […]