Friendship Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 8, 2022

  Based on observation, interview, and record review, the facility failed to ensure interventions were implemented for a resident (R1) assessed as high risk for wandering, failed to provide supervision when a wandering, cognitively impaired resident (R1) exited the hallway via a wheelchair into an unattended, unalarmed stairwell and failed to ensure that the Short Stay Rehab 1 Main door was alarmed to notify staff of an unsupervised resident in a stairwell. These failures resulted in R1 not being adequately supervised and exiting the unattended, unalarmed door, into the facility stairwell on 11/20/22 around 5:30 P.M. […]

• Actual harm, isolatedF689Sep 12, 2025

  Based on interview and record review, the facility failed to ensure 1 of 3 residents (R1) was transferred safely. This failure resulted in R1 falling and fracturing her right femur.The findings include: On 9/12/25 at 12:45 PM, V9 (Certified Nursing Assistant/CNA) said she was R1's CNA when R1 fell on the morning of 9/2/25. V9 said a couple days prior when she was caring for R1, R1 complained of arm pain and wanted to get up in her chair because of her arm pain. The morning of 9/2/25, R1 complained of right arm pain again and asked V9 to put her in her chair (recliner). V9 said she changed and dressed R1 with pants, shoes, socks, and a clean brief, then she helped position R1 on the side of her bed. […]

• Actual harm, isolatedF689Apr 9, 2025

  Based on observation, interview, and record review the facility failed to ensure a resident was safely positioned in bed for 1 of 3 residents (R2) reviewed for safety in the sample of 5. This failure resulted in R2 falling from her bed and sustaining a laceration requiring staples. The findings include: R2's physician visit form documents she was admitted to the facility on [DATE] with multiple diagnoses including vascular dementia, and history of falling. R2's quarterly resident assessment and care screening of 2/17/25 documents her to have severe cognitive impairment. Her mobility assessment shows she requires substantial/maximal assistance with rolling right to left. Meaning the helper provides more than half of the effort to perform the task. […]

• Actual harm, isolatedF689Jul 24, 2024

  Based on observation, interview, and record review the facility failed to follow the facility's fall program and provide supervision for three (R15, R18, and R60) of six residents reviewed for falls in the sample of 28. These failures resulted in: R15's hospitalization resulting from nasal fractures; R18's hospitalization resulting from a tibial fracture; and R60's hospitalization s resulting from a right hip fracture and then left hip fracture. Findings include: The facility's undated Managing Falls and Fall Risk policy and procedure, documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. […]

• Actual harm, isolatedF600May 16, 2023

  Based on observation, interview and record review, the facility failed to protect a resident from mental and emotional abuse for one of three residents (R1) reviewed for abuse in the sample of three. This failure resulted in (R1) verbalizing feeling demeaned, degraded, and angry. Findings include: The facility's Abuse, Neglect and Exploitation Prevention policy, dated 2/24/23, documents Our residents have the right to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment and involuntary seclusion. […]