Friends House

The facility underwent a Case Management visit to review fire clearance and address a recent elopement incident. The report details the inspection of a newly cleared SFD unit and a discussion regarding the resident's elopement history and current care plan. No deficiencies were cited during this visit.

The inspection identified two deficiencies: one Type A citation regarding medication recordkeeping and one Type B citation concerning resident elopement protocols. The Type A deficiency poses an immediate risk, while the Type B deficiency relates to potential lapses in resident safety and supervision. Both deficiencies were cited with a Plan of Correction due date of 11/03/2025.

The investigation was conducted following a complaint regarding the facility's management of resident incontinence needs. The allegation was found to be substantiated because the facility could not provide written incontinence care protocols. The primary deficiency cited relates to failing to ensure residents' medical needs, specifically incontinence care, are adequately addressed.

The unannounced annual inspection revealed several deficiencies related to resident health records and staff training compliance. Specifically, two residents were found without current TB clearances, and staff members were noted to be deficient in completing required annual training hours. The facility must submit updated documentation for these items by the specified Plan of Correction due dates.

This report details a complaint investigation conducted following an unannounced visit. The allegations regarding staff failing to prevent resident smoking and staff not providing a comfortable environment were both found to be unsubstantiated. The facility was noted to have taken corrective actions, such as providing an alternative smoking location, to address the concerns.

The inspection identified three deficiencies related to staff training, resident medical assessments, and updating resident care plans. All cited deficiencies were classified as Type B (non-compliance). The facility was required to submit several documents and complete training/updates by January 5, 2024.

The inspection was a Case Management-Incident review conducted on June 16, 2023. The evaluator noted that the facility was clean, at a comfortable temperature, and all exits were unobstructed. No deficiencies were cited during this visit.

The investigation report details findings from a complaint investigation conducted on April 10, 2023, with the report finalized on April 28, 2023. The primary deficiency cited relates to staff training, specifically the lack of current First Aid certification for multiple staff members. These deficiencies are classified as Type A, indicating an immediate health or safety risk.