Friendship Home Association

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 20, 2023

  Based on observation, interview with staff and family, clinical record review and facility policy review the facility failed to provide adequate supervision to prevent accidents for 2 of 6 residents reviewed (Resident #6 and #1). Resident #6 had periods of restlessness and would attempt to get out of bed on his own. He had many falls and it was discovered that the fall mat next to his bed was a risk hazard. The fall mat was displaced upon one unwitnessed fall when he sustained a major injury. Resident #1 had a fall while on the fall mat next to her bed so the mat had been removed. Staff continued to put the mat next to her bed after the intervention had been discontinued. The facility reported a census of 43 residents. […]

• Actual harm, isolatedF689Jun 30, 2022

  Based on review of the Facility Reported Incident (FRI), staff interviews, and clinical record review, the facility failed to implement a bedside fall mat to prevent an injury for one of three residents reviewed for falls (Resident #192). This failure resulted in harm, a subarachnoid hemorrhage (brain bleed), when Resident #192 fell from the bed onto the floor. The facility reported a census of 42 residents. Findings include: Review of the Face Sheet, located in the electronic medical record (EMR), revealed Resident #192 was admitted to the facility on [DATE] with diagnoses that included cerebral ischemia (stroke) and [CONDITION(S)] (poor circulation). […]

• No harm, potential for more than minimal, widespreadF812Jul 30, 2026

  Based on direct observation, faciliy document review, staff interview, and facility policy review, the facility failed to perform regular temperature and sanitation chemical monitoring for their dishwashing unit. The facility reported a census 41. Findings include: During a direct observation on 07/27/2026 at 10:30 AM the Initial kitchen audit revealed the July 2026 Dishwashing temperatures and chemical sanitation testing log had not been completed since 07/17/2026. The chlorine chemical solution in the dishwasher was noted to be low but still present at the time of this inspection. Additionally, the log did not have documentation on 07/16/2026, 07/14/2026, 07/09/2026, 07/02/2026, and 07/01/2026. […]

• No harm, potential for more than minimal, patternF628Jul 30, 2026

  Based on clinical record review, and staff interviews, the facility failed to ensure the completion of comprehensive discharge summaries-specifically the recapitulation of stay-for 3 of 3 residents sampled (Resident #43, #44, and #45). The facility failed to ensure that mandatory discharge elements, including a summary of diagnoses, course of illness, treatment, therapy, and pertinent diagnostic results, were generated and maintained in the medical record for residents upon discharge. […]

• No harm, potential for more than minimal, patternF641Jul 30, 2026

  Based on clinical record review, staff interviews and guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately complete Section P (Restraints and Alarms) of the Minimum Data Set (MDS) for 5 of 5 residents sampled (Residents #1, #3, #7, #26, #35). Specifically, the facility erroneously coded the use of bed rails as physical restraints on the MDS assessments. The facility reported a census of 41 residents. […]