Friends Nursing Home

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to maintain a comfortable and homelike environment for Residents. This finding was found to be evident in 7 Resident rooms (rooms 201, 204, 210, 215, 218, 219 and 222) out of 22 Resident rooms reviewed for a safe, clean, comfortable, homelike environment during the annual recertification survey.

Inspectors wroteBased on observations, staff interviews and surveyor record reviews it was determined that the facility failed to maintain sanitary conditions for food in accordance with professional standards for food service safety. This finding was found to be evident during the review of the kitchen and the nourishment refrigerator on the nursing unit during the annual recertification survey.

Inspectors wroteBased on record reviews, and staff interviews, it was determined that the facility failed to ensure that residents on psychotropic medications have behavior monitoring interventions in place. This was evident for 3 (#31 , #70, #73) of 5 residents reviewed for unnecessary medication during the annual survey.

Inspectors wroteBased on staff interviews and record reviews it was determined that the facility failed to monitor a Resident for adverse side effects of usage of a high-risk medication. This finding was found to be evident in 1 (Resident #59) out of 3 Residents reviewed for falls and accidents.

Inspectors wroteBased on observations, staff interviews and surveyor record review it was determined that the facility failed to label and store medications in a locked, secure area and inaccessible to unauthorized staff, visitors and Residents. This finding was found to be evident in 1 (Resident #11) out of 12 Residents reviewed for medication storage during the annual recertification survey.

Inspectors wroteBased on observations and staff interviews it was determined that the facility staff failed to maintain infection prevention and control practices. This finding was found to be evident on the [NAME] Nursing Unit reviewed for infection control practices during the annual recertification survey.

Inspectors wroteBased on the main kitchen tour and staff interviews, it was determined that the facility failed to store, monitor, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure a homelike environment. This was evident for 13 out of 13 resident rooms reviewed during the survey.

Inspectors wrote2. On 5/14/25 at 8:28 AM, record review revealed that the incident took place on 1/14/25 during breakfast. Incident report revealed that Resident #12 experienced second degree burns with 3 clustered blisters to the Left thigh where Resident #12 spilled hot coffee onto themselves. On 1/16/25 the facility started their investigation with staff interviews and with Resident #12 being evaluated for their injuries by wound services. The facility reported the incident to the State Survey Agency on 1/21/25 at 10:32 AM. Further review of the incident showed that the report was not complete within the 5 days as required. Closing of the investigation by the facility was not reported to the State Survey Agency until 1/29/25. On 5/9/25 at 9:30 AM An interview with Administrator #2 and DON was conducted. [...]

Inspectors wroteBased on medical record review, interviews, and observations it was determined that the facility failed to create, revise and update the resident's care plan in a timely fashion. This was evident for 1 (#48) of 4 resident care plans reviewed during the survey.

Inspectors wroteBased on medical record review, interviews, and observations it was determined that the facility failed to revise and update the resident's care plan in a timely fashion. This was evident for 1 (#48) of 4 resident care plans reviewed during the survey.

Inspectors wroteBased on observations, family and staff interviews, and record review, it was determined that the facility failed to manage pain for residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was evident for 1 (Resident #56) out of 28 residents observed during the survey.

Inspectors wroteBased on observations, record review and interviews, it was determined that the facility failed to: 1) maintain Infection Prevention & Control based on when and how isolation should be used for a resident. This was evident for 1 resident (#54) out of 20 residents reviewed during survey; 2) conduct an annual review of its Infection Prevention and Control Program (IPCP) and update their program, as necessary. This was evident during a review of the facility's Antibiotic Stewardship Program policy and procedures for infection control.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that essential equipment to be in safe operating condition. This was evident for 2 out of 13 resident rooms reviewed during the survey.

Inspectors wroteBased on record review, facility document review, interview, and facility policy review, the facility failed to report an allegation of abuse to the state survey agency within two hours for 1 (Resident #6) of 3 residents reviewed for abuse.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a physician's order for medicated eye drops was followed and the eye drops not administered until after surgery for 1 (Resident #3) of 3 residents reviewed for medications. Resident #3 had eye drops ordered to be administered three times daily for seven days after surgery, and the eye drops were administrated prior to the surgery.

Inspectors wroteBased on record review and staff interview it was determined that facility staff failed to develop a base line care plan for respiratory care for Resident #200. This finding was evident in 1 of 16 residents reviewed during the survey. On 05-17-21 Resident #200 observed lying in bed with oxygen on at two liters per minute (LPM) via nasal cannula. The resident was experiencing shortness of breath while speaking. On 05-17-21 review of the clinical record revealed a hospital Discharge summary dated [DATE] that noted Resident #200 had been admitted to the hospital for shortness of breath and reported being constantly SOB but the resident was not hypoxic. Review of the physician's orders for Resident #200 revealed an order from the date of admission on [DATE] for oxygen to be administered via nasal cannula at 2 LPM, continuously. [...]

Inspectors wroteBased on surveyor review of the clinical record, surveyor observation of medication pass and interview with facility staff, it was determined that the facility failed to ensure nursing standards of practice in the timely medication administration for residents. This finding was evident for 2 of 11 residents observed during the medication observation of facility residents (Residents #8 and #17).

Inspectors wroteBased on review of employee records and facility staff interview, it was determined that the facility failed to complete annual performance reviews. This finding was evident for 3 of 3 Geriatric Nursing Assistan (GNA) records reviewed (GNA #2, #3, and #4). 1. On 05-20-21 survey review of employee file for GNA #2 revealed no evidence of an annual performance review for 2020. On 05-20-21 at 3:000 PM surveyor interview with the administrator provided no additional information. 2. On 05-20-21 survey review of employee file for GNA #3 revealed no evidence of an annual performance review for 2020. On 05-20-21 at 3:00 PM surveyor interview with the administrator provided no additional information. 3. On 05-20-21 survey review of employee file for GNA #4 revealed no evidence of an annual performance review for 2020. [...]