Inspection Reports for Friends House

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements for the assisted living portion of the facility.

The inspection found the facility generally compliant with regulations, including safe food storage, proper environmental conditions, and complete resident and staff records. However, two deficiencies were cited related to medication recordkeeping and resident elopement.

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements for the assisted living portion of the facility.

The inspection found the facility generally compliant with safety and environmental standards, including food storage, fire safety, and emergency preparedness. However, deficiencies were cited for two residents lacking TB clearance and two staff members not completing the required 20 hours of annual training.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not preventing a resident from smoking in the facility and not providing a comfortable environment for residents.

Both allegations were found to be unsubstantiated due to lack of preponderance of evidence. The facility had taken steps to address smoking concerns, and interviews with residents indicated no discomfort from smoke or evidence supporting the allegations.

The complaint investigation was unsubstantiated. Allegations included staff not preventing resident smoking in unauthorized areas and not providing a comfortable environment. The investigation found no sufficient evidence to prove the violations occurred.

An unannounced Required - 1 Year annual inspection was conducted to evaluate compliance with regulations for the assisted living portion of the facility.

The inspection found several deficiencies including outdated resident care plans for 6 out of 9 residents, one resident lacking a current medical assessment, and 2 out of 5 staff missing required annual training hours. The facility environment and safety measures were generally compliant.

The inspection was conducted as a Case Management-Incident visit following an incident report regarding a resident fall and denial of medical treatment.

No deficiencies were cited during the inspection. The facility was found clean, with unobstructed exits, and ongoing construction was observed. The importance of timely incident reporting was discussed.

The visit was complaint-related due to an incident on February 8, 2023 involving a resident fall and denial of medical treatment. The resident later had a CT scan on June 2, 2023 revealing a mild fracture. The complaint was discussed but no deficiencies were cited.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff do not possess current first aid certificates and that staff are not properly trained.

The complaint that staff did not possess current first aid certificates was substantiated, with 2 out of 5 staff lacking valid First Aid/CPR cards, posing an immediate risk to residents. The complaint that staff were not properly trained was unsubstantiated, as evidence showed sufficient training and proper medication distribution.

The complaint investigation was substantiated for the allegation that staff do not possess current first aid certificates. The allegation that staff are not properly trained was unsubstantiated due to insufficient evidence.

The inspection was a Required 1-Year unannounced inspection focused on Infection Control procedures and practices at the facility.

The facility was found to be clean and orderly with sufficient PPE supplies, proper medication security, and no deficiencies cited during the inspection.

The inspection was conducted as an unannounced complaint investigation following allegations that the facility was not following proper COVID-19 protocols, staff were not wearing masks, and a staff member yelled at residents.

The investigation found that staff and residents were observed wearing masks during visits, COVID-19 protocols and PPE were in place, and interviews with residents and staff did not substantiate the allegations. Therefore, all allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included failure to follow COVID-19 protocols, no mask wearing, and staff yelling at residents. Interviews and observations did not provide sufficient evidence to substantiate these claims.

An unannounced annual inspection was conducted focusing on the Infection Control procedures and practices of the facility.

The facility was found to be clean, in good repair, and compliant with infection control protocols including PPE use, vaccination rates, and COVID-19 mitigation measures. No deficiencies were cited during the inspection.

The visit was an unannounced complaint investigation triggered by an allegation that staff did not ensure a resident received transportation.

The investigation found the complaint to be unfounded, determining that the allegation was false, could not have happened, and/or was without reasonable basis. The facility does not prohibit residents from using other transportation and has developed a plan to provide transportation services during the Shelter in Place order.

Complaint alleged staff did not ensure resident received transportation. The complaint was investigated and found to be unfounded.

The inspection was a case management visit conducted via tele-video due to COVID-19 precautions, regarding a request for a capacity increase from 80 to 105 non-ambulatory residents, including 7 bedridden residents.

The inspection found that the prior skilled nursing area was converted to the assisted living section, with all rooms equipped with call systems, proper grab bars, and necessary amenities. A fire clearance was approved for the capacity increase. No deficiencies were cited during the visit.