Friendship Haven Healthcare and Rehabilitation Cen

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) of enteral feeding for 1 (Resident #56) of 8 residents reviewed for enteral nutrition. The facility failed to ensure LVN A used the appropriate procedure for checking placement and administering flushes and medication during medication administration. The facility failed to ensure LVN A did not use air to check for placement. The facility failed to ensure LVN A used the appropriate amount of water to dilute medication and to flush in between medication administration. These failures could have placed residents with a gastrostomy tube at risk for complications, aspiration, and pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 12%, based on 3 errors out of 25 opportunities, which involved 1 (Resident #56) of 5 residents reviewed for medication errors. The facility failed to ensure/ prevent when LVN A left a substantial amount of medication residue for Amlodipine 5mg give 1 tab via G-tube two times a day, Coreg Oral Tablet 6.25 MG (Carvedilol) give 1 tablet via G-Tube two times a day, and Lansoprazole 30mg give 1 tablet via G-Tube two times a day in the medication cups after medications were administered through a g-tube to Resident #56. These failures could have placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 4 residents (CR #2) reviewed for discharge requirements. The facility failed to ensure CR #2 was readmitted to the facility, after being sent to the hospital for evaluations due to change in condition. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services. A record review of CR #2's electronic face sheet revealed reflected an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 3 residents reviewed for PASRR services. The facility failed to submit Resident #1's NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health. Record review of Resident #1's face sheet dated 09/03/25 revealed a [AGE] year-old female, admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 9 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control practices. 1. The facility failed to ensure ADON A and the Restorative Aide applied enhanced barrier precautions while transferring Resident # 1 from her wheelchair to her bed. 2. The facility failed to ensure that CNA J and CNA G sanitized their hands when providing incontinent care to Resident #2 and Resident #3. These failures could place residents at risk of cross-contamination and infections leading to illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse for 1 of 6 residents (Resident #79) reviewed for abuse. The facility failed to keep Resident #79 free from abuse when RN A yelled at and hit the resident while attempting to give her medication on 10/6/24 at 4:00 AM. The noncompliance was identified as past noncompliance (PNC). The facility corrected the noncompliance before the survey began. This failure could place residents at risk of experiencing and enduring abuse causing a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received meals at regular times comparable to normal mealtimes in the community or in accordance with resident needs and preferences for three of three days (11/04/24, 11/05/24, and 11/06/24) reviewed for frequency of meals. -The facility failed to ensure residents received meals at regularly scheduled times for breakfast and lunch on 11/04/24, breakfast and lunch on 11/05/24, and breakfast on 11/06/24. This failure could place residents who eat from the facility's kitchen, at risk of loss of appetite, weight loss, increased hunger, thirst, frustration, and decreased feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary, and homelike environment for 2 of the 5 residents observed for environment. The facility failed to ensure Resident # 1 and Resident #2 room was sanitary and homelike. This failure could place residents at risk of not receiving a safe, clean, comfortable, and homelike environment to attain or maintain their highest practicable physical, mental, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to, based on the comprehensive assessment of a resident, ensure that the residents received treatment and care in accordance with professional standards of practice, the comprehensive Person - centered care plan, and the resident's choices for one out of three residents (Resident number # 91) reviewed for quality of care. - The facility failed to promptly assess, identify, and treat skin tear under the left fold before the abdomen, rashes close to the under-abdomen fold, and groin on Resident #91 and failed to ensure interventions were implemented to treat and prevent further skin deterioration. This failure could place residents at risk for a delay of care or treatment, pain, and suffering.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that 4 Frozen rolls of 10 lb. ground beef in a pan being thawed in the sink. This failure could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 08/29/23 at 8:30 AM revealed 4- 10 lb. frozen ground beef in a pan being thawed in the sink faucet water running with a temperature of 91 degrees Fahrenheit. Ground beef had an internal temperature of 73.8 degrees Fahrenheit indicating that the temperature is in the Danger Zone (41 degrees Fahrenheit to 135 degrees Fahrenheit). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 4 of 8 residents (Resident #91, Resident #11, Resident #50 and, Resident #4) reviewed for ADLs. 1. The facility failed to ensure Resident #91 was provided shower or bed bath for two weeks which caused the resident's skin to be dry and flaky. 2. The facility failed to ensure Resident # 11 was provided grooming (shaving and nail care). 3. The facility failed to ensure Resident # 50 was provided grooming (nail care). 4. The facility failed to ensure Resident #4 was provided grooming (shaving) These failures could place residents at risk for discomfort, and dignity issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #91) reviewed for notification of changes in that: The facility failed to notify Resident #91's physician when Resident #91 presented with skin tear under her skin fold before the abdomen, rashes on the abdomial folds and peri - area. This deficient practice could place residents at risk of not having their physician informed when there was a change in condition resulting in a delay in medical intervention and decline in health.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure resident was free from significant medication errors for Resident #109 reviewed for significant medication errors. -The facility failed to ensure that Resident #109's anticonvulsant medications was administered as ordered by his physician. This failure could affect residents who received medication placing them at risk of not receiving the therapeutic effect of the mediations and could result in declining health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 6 residents (Resident #91) observed for accuracy of medical records in that: The facility failed to discontinue Resident #91's skin tear and rashes on progress notes and weekly skin assessment. This deficient practice could place residents at risk for errors in care and treatment.