Deficiencies (last 23 years)
Deficiencies (over 23 years)
0.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% better than West Virginia average
West Virginia average: 9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
41 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Oct 22, 2025
Visit Reason
Investigation of Complaint #39992 regarding facility conditions and care.
Complaint Details
Complaint #39992 was investigated on 10/22/25; it was found unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Report Facts
Census: 41
Inspection Report
Follow-Up
Census: 43
Deficiencies: 0
Date: Aug 25, 2025
Visit Reason
Follow-up to Annual Survey to verify correction of previously identified deficiencies.
Findings
The deficiency identified in the prior annual survey was corrected as of the follow-up visit.
Report Facts
Census: 43
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 1
Date: Jun 25, 2025
Visit Reason
The inspection was conducted as an annual survey of Elmhurst, The House of Friendship, Inc. to assess compliance with health and safety regulations and review resident health assessments.
Findings
A deficiency was cited for failure to ensure each resident's record contained an annual written, signed, and dated health assessment including tuberculosis screening. The assessment for one resident was late and incomplete. The facility also had deficiencies related to housekeeping and maintenance observed during a prior behavioral health survey.
Deficiencies (1)
Failure to ensure each resident's record contained an annual written, signed, and dated health assessment including tuberculosis screening; one resident's assessment was late and incomplete.
Report Facts
Census: 11
Sample size: 10
Deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 0
Date: Jul 17, 2024
Visit Reason
The inspection was conducted as an annual survey of the facility to assess compliance with regulatory standards.
Findings
The annual survey conducted from 07/15/24 to 07/17/24 found no deficiencies cited at the facility.
Report Facts
Census: 37
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 0
Date: Jul 15, 2024
Visit Reason
Annual environmental inspection of Elmhurst, The House Of Friendship WV conducted on July 15, 2024.
Findings
No deficiencies were cited during this annual environmental inspection.
Report Facts
Census: 40
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
The inspection was conducted as an annual survey of the facility.
Findings
The report documents the annual survey with a census of 35 residents. No specific deficiencies or severity levels are detailed in the provided page.
Report Facts
Census: 35
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
Annual environmental inspection of Elmhurst, The House Of Friendship WV conducted on August 2, 2023.
Findings
No deficiencies were cited during this annual environmental inspection.
Report Facts
Census: 35
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 0
Date: Jul 28, 2022
Visit Reason
The visit was conducted as an annual survey to assess the facility's compliance with regulatory standards.
Findings
The inspection found no citations or deficiencies during the annual survey conducted from July 25 to July 28, 2022, with a census of 39 residents.
Report Facts
Census: 39
Citations: 0
Inspection Report
Follow-Up
Census: 39
Deficiencies: 0
Date: Jul 25, 2022
Visit Reason
The visit was a complaint follow-up inspection to verify correction of previous deficiencies.
Complaint Details
Complaint Follow-Up #26733; no new citations were written, indicating the complaint was addressed.
Findings
The inspection cleared all tags with no new citations written, indicating that previous deficiencies were addressed.
Report Facts
Census: 39
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 0
Date: Jul 20, 2022
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with state requirements.
Findings
The residence was found to be in substantial compliance with the applicable rules based on review of documentation, staff interviews, observations, and performance testing.
Report Facts
Sample size: 100
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 4
Date: May 17, 2022
Visit Reason
Complaint survey #26733 was conducted from 05/16/22 to 05/17/22 to investigate allegations related to resident care and facility compliance.
Complaint Details
Complaint survey #26733 was substantiated. The investigation found failures in monitoring residents post-incident, timely communication with licensed professionals, and neglect of resident #35.
Findings
The facility failed to ensure staff monitored and documented residents' conditions every eight hours for 24 hours following incidents for three residents. Additionally, staff failed to timely contact licensed health care professionals after incidents, and the facility did not ensure adequate housekeeping and maintenance. One resident was neglected when staff delayed notifying the nurse after a fall.
Deficiencies (4)
Failed to monitor and document resident's condition at least once every eight hours for 24 hours following incidents for residents #5, #22, and #35.
Failed to contact an appropriately licensed health care professional timely after resident #35's fall to assess severity and advise treatment.
Failed to ensure no resident was neglected; delayed notification of nurse after resident #35's fall and failure to follow emergency procedures.
Failed to ensure adequate housekeeping and maintenance; observed personal belongings behind dresser, iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink.
Report Facts
Census: 35
Incident evaluations required: 3
Incident evaluations completed late: 7
Time delay in notification: 6.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Assistant #32 | Resident Assistant | Found resident #35 on the floor after fall. |
| Approved Medication Assistive Personnel #26 | AMAP | Notified of resident #35's fall, documented injuries, delayed notifying nurse and resident's son. |
| Registered Nurse (RN) | Registered Nurse | Responsible for assessing residents post-incident; not notified timely after resident #35's fall. |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 0
Date: Aug 18, 2021
Visit Reason
The visit was conducted as an annual survey to assess compliance with regulatory standards.
Findings
The inspection found no citations or deficiencies during the annual survey conducted from August 10 to August 18, 2021.
Report Facts
Census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sherry Rapp | HFNSII | Named in the initial comments section of the annual survey |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 0
Date: Aug 9, 2021
Visit Reason
Annual environmental inspection of Elmhurst, The House Of Friendship WV.
Findings
The inspection found no deficiencies cited during the visit.
Report Facts
Census: 35
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Apr 1, 2021
Visit Reason
The inspection was conducted as a complaint investigation (Complaint Investigation #25088) to determine the validity of the complaint received.
Complaint Details
Complaint Investigation #25088 was unsubstantiated.
Findings
The complaint was found to be unsubstantiated following the investigation conducted from 03/30/21 to 04/01/21.
Report Facts
Census: 36
Inspection Report
Routine
Census: 38
Deficiencies: 0
Date: Jan 28, 2021
Visit Reason
The inspection was conducted as an infection control survey to assess compliance with infection control standards at the facility.
Findings
No deficiencies were cited during the infection control survey conducted at the facility.
Report Facts
Census: 38
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 0
Date: Jul 8, 2020
Visit Reason
The visit was conducted as an annual survey to assess compliance with regulatory requirements.
Findings
The report documents the initial comments of the annual survey conducted from July 6 to July 8, 2020, with a census of 42 residents. No specific deficiencies or severity levels are detailed in the provided page.
Report Facts
Census: 42
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 0
Date: Jun 1, 2020
Visit Reason
Annual environmental inspection of Elmhurst, The House Of Friendship WV.
Findings
The inspection found no deficiencies cited during the annual environmental survey.
Report Facts
Census: 43
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 0
Date: Apr 17, 2019
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory requirements for Elmhurst, The House of Friendship.
Findings
No deficiencies were cited during this annual licensure survey. The facility was found to be in compliance with all applicable standards.
Report Facts
Census: 44
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 0
Date: Apr 10, 2019
Visit Reason
Annual licensure survey conducted to assess environmental conditions and compliance with regulatory standards.
Findings
The facility was found to have no deficiencies cited during the annual licensure survey.
Report Facts
Census: 44
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 4
Date: Apr 11, 2018
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with health care standards and medication administration regulations.
Findings
The facility was found deficient in ensuring that resident care was provided by appropriately licensed health care professionals and that medications and treatments were administered according to applicable laws. Specifically, there were issues with missing physician orders for medications, medications listed on MARs without physician orders, and lack of monthly RN review of MARs.
Deficiencies (4)
Failure to ensure resident care was provided by appropriately licensed health care professionals and that medications and treatments were administered as required by law.
Missing physician orders for medications for five of six residents reviewed.
Medications listed on MARs without signed physician orders.
No documentation that the RN reviewed MARs monthly as required.
Report Facts
Census: 44
Residents reviewed: 6
Residents with medication issues: 5
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Named in findings related to failure to review MARs monthly and medication administration oversight | |
| Administrator | Named in findings related to medication administration compliance |
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 1
Date: Apr 9, 2018
Visit Reason
The inspection was conducted as an annual licensure survey of the facility.
Findings
A deficiency was cited during the annual licensure survey conducted April 9-11, 2018. A follow-up survey on June 5, 2018, found the deficiencies corrected.
Deficiencies (1)
Deficiency cited during the annual licensure survey.
Report Facts
Census: 44
Census: 42
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 0
Date: Apr 3, 2018
Visit Reason
The visit was conducted as an annual licensure survey to assess environmental compliance at the facility.
Findings
The inspection found no deficiencies cited during the annual licensure survey.
Report Facts
Census: 41
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 0
Date: Apr 12, 2017
Visit Reason
The visit was conducted as an annual licensure survey to assess environmental conditions and compliance with regulatory requirements.
Findings
The survey found no deficiencies cited during the annual licensure inspection.
Report Facts
Census: 39
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 0
Date: Mar 6, 2017
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with regulatory requirements.
Findings
The facility was found to have no deficiencies during the annual licensure survey conducted from March 6-8, 2017.
Report Facts
Deficiencies cited: 0
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 0
Date: Apr 5, 2016
Visit Reason
The visit was conducted as an annual licensure survey to assess environmental conditions and compliance with regulatory standards.
Findings
The inspection found no deficiencies related to the environmental conditions of the facility during the annual licensure survey.
Report Facts
Census: 37
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 0
Date: Mar 24, 2016
Visit Reason
The inspection was conducted as an annual licensure survey of the facility.
Findings
The report documents the annual licensure survey conducted on March 23-24, 2016, with a census of 39 residents. No specific deficiencies or severity levels are detailed in the provided text.
Report Facts
Census: 39
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 1
Date: Apr 14, 2015
Visit Reason
Annual licensure survey conducted to assess compliance with licensing requirements including disaster and emergency preparedness.
Findings
The facility failed to review and update the disaster and emergency preparedness plan on an annual basis and did not have documented evidence of such review for 2014.
Deficiencies (1)
Failure to review and update the disaster and emergency preparedness plan annually and to sign and date the plan to verify review.
Report Facts
Census: 44
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 0
Date: Apr 20, 2014
Visit Reason
The visit was conducted as an annual licensure survey of the facility.
Findings
The report documents the annual licensure survey conducted from April 20 to 22, 2014, with a census of 44 residents. No specific deficiencies or severity levels are detailed in the provided text.
Report Facts
Census: 44
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 0
Date: Apr 1, 2014
Visit Reason
The visit was conducted as an annual licensure survey to assess compliance with regulatory requirements.
Findings
The facility was found to have no deficiencies during the annual licensure survey conducted on April 1, 2014.
Report Facts
Census: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Named in the report as associated with the annual licensure survey |
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 0
Date: Mar 12, 2014
Visit Reason
The inspection was conducted as an annual licensure survey of the facility.
Findings
The report documents the annual licensure survey conducted from March 10-12, 2014, with a census of 45 residents. No specific deficiencies or severity levels are detailed in the provided report.
Report Facts
Census: 45
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 0
Date: Apr 17, 2013
Visit Reason
The visit was conducted as an annual licensure survey of the facility.
Findings
No deficiencies were cited during the survey, and technical assistance was provided to the facility.
Report Facts
Census: 34
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 28, 2013
Visit Reason
The document is an annual licensure survey conducted to assess environmental compliance at the facility.
Findings
The annual licensure survey conducted on March 27-28, 2013 found no deficiencies cited and no technical assistance was given.
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 0
Date: Apr 4, 2012
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory requirements for the facility.
Findings
No deficiencies were cited during the annual licensure survey conducted on April 4, 2012.
Report Facts
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 0
Date: Mar 20, 2012
Visit Reason
The facility underwent an annual licensure survey conducted on March 20-21, 2012 to assess compliance with regulatory requirements.
Findings
No deficiencies were cited during the survey. Technical assistance was provided to the facility.
Report Facts
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Surveyor during the annual licensure survey |
| Louise Hall | RN HFNS II | Surveyor during the annual licensure survey |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Date: Jun 27, 2011
Visit Reason
The inspection was conducted as a complaint investigation for WV#00006465 from June 27-30, 2011.
Complaint Details
Complaint investigation WV#00006465 was unsubstantiated.
Findings
The complaint investigation was unsubstantiated with no deficiencies cited.
Report Facts
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Surveyor during complaint investigation |
| Louise Hall | RN, HFNS II | Surveyor during complaint investigation |
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 0
Date: Apr 27, 2011
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory requirements for the facility.
Findings
No deficiencies or technical assistance were identified during the survey.
Report Facts
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 0
Date: Mar 16, 2011
Visit Reason
The document is an annual licensure survey conducted to assess compliance with regulatory requirements for the facility.
Findings
No deficiencies were cited during the survey. Technical assistance was provided to the facility.
Report Facts
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Surveyor during the annual licensure survey |
| Louise Hall | RN, HFNS II | Surveyor during the annual licensure survey |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 0
Date: Apr 7, 2010
Visit Reason
The facility underwent an annual licensure survey conducted from April 5-7, 2010 to assess compliance with regulatory standards.
Findings
No deficiencies were identified during the survey, and technical assistance was provided to the facility.
Report Facts
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Surveyor during the annual licensure survey |
| Louise Hall | RN, HFNS II | Surveyor during the annual licensure survey |
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 0
Date: Mar 1, 2010
Visit Reason
The visit was conducted as an annual licensure survey to assess compliance with regulatory requirements.
Findings
No deficiencies were cited during the survey, although technical assistance was provided to the facility.
Report Facts
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason T. Lintner | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 33
Capacity: 12
Deficiencies: 0
Date: Apr 21, 2009
Visit Reason
The inspection was conducted as an annual licensure survey to assess the environment and readiness of the facility, including a new twelve-room addition nearing completion.
Findings
No deficiencies or technical assistance were noted during the inspection. The facility is preparing to admit new residents pending final fire marshal approval.
Report Facts
New beds: 12
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 0
Date: Apr 14, 2009
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory requirements.
Findings
No deficiencies were found during the survey. Technical assistance was provided.
Report Facts
Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Surveyor |
| Louise Hall | RN HFNS II | Surveyor |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 0
Date: Apr 9, 2008
Visit Reason
The visit was conducted as an annual licensure survey to assess compliance with regulatory requirements.
Findings
The report documents the annual survey findings for Elmhurst, The House of Friendship, Inc. The census at the time was 35 residents. Specific deficiencies or severity levels are not detailed in the provided text.
Report Facts
Census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Louise Hall | HFNS II | Surveyor for the annual licensure survey |
| Betty Marine | LSW, HFS II | Surveyor for the annual licensure survey |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 0
Date: Apr 3, 2008
Visit Reason
The visit was conducted as an annual licensure survey to assess the facility's compliance with regulatory standards.
Findings
The inspection found no deficiencies or technical assistance needs related to the environment during the annual licensure survey.
Report Facts
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 3
Date: May 9, 2007
Visit Reason
The facility underwent an annual licensure survey to assess compliance with health, safety, and environmental regulations.
Findings
The inspection identified deficiencies including unsanitary conditions in the food preparation area, unsafe hot water temperatures exceeding 120°F, and environmental maintenance issues such as damaged carpet, missing bathroom fixtures, and inadequate housekeeping.
Deficiencies (3)
Food preparation area had heavy accumulation of old food splatter and grease on stainless steel shelves over the steam table.
Hot water temperatures measured at 127.5°F, exceeding the safe limit of 120°F.
Environmental maintenance issues including iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink.
Report Facts
Census: 37
Hot water temperature: 127.5
Deficiency completion date: May 18, 2007
Deficiency completion date: May 15, 2007
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Named in relation to the annual licensure survey |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 0
Date: May 9, 2007
Visit Reason
The visit was conducted as an annual licensure survey to assess the facility's compliance with regulatory requirements.
Findings
The inspection focused on the environment of the facility. A follow-up survey was conducted to verify correction of deficiencies, which were found to be corrected.
Report Facts
Census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey and follow-up survey |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 0
Date: Mar 28, 2007
Visit Reason
The inspection was conducted as an annual licensure survey of the facility.
Findings
The report documents the annual licensure survey with no specific deficiencies or severity levels noted in the provided text. The census at the time of inspection was 37 residents.
Report Facts
Census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Named as part of the survey team |
| Louise Hall | RN HFNS II | Named as part of the survey team |
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 0
Date: Apr 19, 2006
Visit Reason
The visit was conducted as an annual licensure survey of the facility.
Findings
The report documents the annual licensure survey conducted on April 18-19, 2006, with a census of 33 residents. No specific deficiencies or severity levels are detailed in the provided page.
Report Facts
Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Named as part of the survey team |
| Louise Hall | RN HFNS II | Named as part of the survey team |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 0
Date: Apr 10, 2006
Visit Reason
The inspection was conducted as an annual licensure survey to assess the environment and compliance of the facility.
Findings
The report notes the environment was inspected during the annual licensure survey. Specific deficiencies or severity levels are not detailed in the provided text.
Report Facts
Census: 37
Inspection Report
Routine
Census: 36
Deficiencies: 0
Date: Apr 12, 2005
Visit Reason
Routine environmental inspection conducted to assess the facility's compliance with health and safety standards.
Findings
No deficiencies were found during the inspection. The administrator reported that the health department has not yet conducted a visit by the sanitarian despite multiple contacts.
Report Facts
Census: 36
Last sanitarian visit: May 21, 2003
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 0
Date: Apr 4, 2005
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards.
Findings
The annual survey found no deficiencies cited during the inspection conducted on April 4-5, 2005.
Report Facts
Resident records reviewed: 6
Employee records reviewed: 9
Inspection Report
Environmental Survey
Census: 36
Deficiencies: 0
Date: Apr 28, 2004
Visit Reason
Environmental survey conducted to assess the facility's compliance with health and safety standards, including handicapped accessibility.
Findings
No deficiencies were issued during the environmental survey. The facility has only one public handicapped toilet/washroom and no other handicapped bathing facilities, with plans to address accessibility in a future building addition.
Report Facts
Census: 36
Inspection Report
Annual Inspection
Census: 6
Deficiencies: 1
Date: Apr 7, 2004
Visit Reason
The visit was conducted as an annual survey of the facility from April 5 to April 7, 2004.
Findings
The inspection found that the facility did not fully implement programs in a safe and appropriate environment for adolescent consumers, specifically noting unsecured outside doors and lack of awake staff supervision on weekend nights.
Deficiencies (1)
The adolescent girls' bedrooms have outside doors without alarms or alert devices, and staff are not awake on weekend nights to monitor consumer safety. Additionally, an outside door in the TV room does not lock.
Report Facts
Center Census: 6
Sample Size: 3
Inspection Report
Annual Inspection
Census: 6
Deficiencies: 3
Date: Feb 11, 2004
Visit Reason
Annual survey conducted to assess compliance with health and safety regulations and adequacy of housekeeping, maintenance, and staff training at Elmhurst, The House of Friendship, Inc.
Findings
The inspection found deficiencies related to safety and environmental conditions, including lack of awake night staff on weekends, unsecured doors, poor housekeeping, maintenance issues such as carpet damage and missing bathroom fixtures, and expired first aid certifications among staff. No formal deficiencies were cited; only technical assistance was provided.
Deficiencies (3)
The Center did not implement programs in a safe environment; adolescent girls' bedrooms had outside doors without alarms and no awake staff on weekend nights.
Inadequate housekeeping and maintenance including personal belongings behind dresser, iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink.
Staff providing services did not have current first aid certification; certifications expired in October 2002.
Report Facts
Center census: 6
Sample size: 3
Deadline for staff deployment for awake-night supervision: Jul 1, 2004
Deadline for carpet replacement: Sep 30, 2004
Number of aids without current first aid certification: 4
Inspection Report
Census: 6
Deficiencies: 1
Date: Feb 11, 2004
Visit Reason
The inspection was conducted as a behavioral health survey to assess the safety and appropriateness of the environment for adolescent consumers.
Findings
The survey found that the facility did not fully implement programs in a safe environment, noting unsecured outside doors in adolescent girls' bedrooms and lack of awake staff supervision on weekend nights. A plan to provide awake-night supervision on weekends was scheduled for implementation by July 1, 2004.
Deficiencies (1)
The adolescent girls' bedrooms have outside doors without alarms or alert devices, and there is no awake staff supervision on weekend nights.
Report Facts
Sample Size: 3
Inspection Report
Deficiencies: 1
Date: Mar 26, 2003
Visit Reason
The inspection was conducted as an Environmental Survey and ADA Follow-Up to assess compliance with the Americans with Disabilities Act (ADA) and ANSI codes applicable to free-standing personal care homes.
Findings
The facility failed to provide handicapped access and handicapped accessible toilet/bathing/washrooms for disabled persons, indicating non-compliance with ADA requirements.
Deficiencies (1)
Handicapped access and handicapped accessible toilet/bathing/washrooms are not provided for disabled persons.
Report Facts
Handicapped accessible units planned: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl K. Jones | Executive Director | Named as responsible for monitoring ADA compliance requirement |
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