Friendship Village of South Hi

In the surveyor’s words

From the most serious findings on record at Friendship Village of South Hi, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF585Dec 2, 2025

  Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents on three of three locations, nursing units (Dogwood, Pinewood, and Specialty Care).Findings include: A review of the facility policy Resident and Family Grievances reviewed 8/13/25, support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The Centers for Medicare & Medicaid Services (CMS) does not specify exact height requirements for grievance boxes in skilled nursing facilities. […]

• No harm, potential for more than minimal, patternF677Dec 2, 2025

  Based on review of facility policy, documents, clinical record review, resident, and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for thirteen of twenty-four residents (Resident R1, R6, R34, R50, R60, R123, R500, R501, R502, R503, R505, R506, and R507). Findings include: Review of facility policy Activities of Daily Living (ADL), Supporting reviewed 8/13/25, indicated resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. […]

• No harm, potential for more than minimal, patternF761Dec 2, 2025

  Based on a review of facility policy, observations, and staff interview, it was determined that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in two of three medication rooms (Secure Care Unit and Dogwood Unit). Findings include: Review the facility policy Medication Labeling and Storage dated 8/13/25, indicated, If the facility has discontinued, outdated, or deteriorated medications or biologicals the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. During an observation of the Secure Care Unit nursing unit medication room on 9/30/25, at approximately 1:15 p.m. […]

• No harm, potential for more than minimal, patternF880Oct 12, 2023

  Based on review of facility policies, review of Centers for Disease Control (CDC) guidelines for Legionella (bacterium that causes Legionnaires Disease found in pipes and heating systems) Control, the facility's infection control tracking logs for water management and staff interviews, it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility. Findings include: Review of the facility policy Health Center Prevention and Control of Legionella last reviewed on 1/27/23, indicated that an interdisciplinary effort will be employed to prevent and control Legionella in the health centers. […]

• No harm, potential for more than minimal, patternF610Dec 1, 2022

  Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to investigate an injuries of unknown origin for three of nine residents (Resident R7, R42, and R43) and failed to investigate an actual allegation of neglect for one of nine residents (R56). Findings include: Review of the facility policy Incident Reports, last reviewed on 3/1/22, indicated that all incidents, unusual occurrences, and injuries will be documented on an incident/accident form. Review of the facility Resident Abuse/Neglect/Exploitation and Reporting Requirements, last reviewed on 3/1/22, with previous review date of 2/28/21, indicated that each resident has a right to be free from abuse, neglect and exploitation. […]