Friendship Health Center

F-F695

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 385121 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385121 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Friendship Health Center 3320 SE Holgate Blvd Portland, OR 97202

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 33179

Residents Affected - Few Based on observation, interview and record review it was determined the facility failed to ensure wheelchairs were clean and sanitary for 1 of 3 sampled residents (#13) reviewed for equipment. This placed residents at risk for unclean wheelchairs. Findings include:

Resident 13 admitted to the facility in 11/2019 with diagnoses including multiple sclerosis (disease which deteriorates the brain and spinal cord) and paraplegia (lower body paralysis).

On 7/22/24 at 10:59 AM Resident 13's wheelchair was observed to have crumbs on the bottom cushion and small (approximately 1 inch by 1 inch) brown smudge marks to the bottom cushion and the inside of the left armrest.

On 7/24/24 at 10:46 AM Resident 13's wheelchair was observed to have crumbs and a small brown smudge (approximately 1 inch by 1 inch) on the bottom cushion.

On 7/26/24 at 12:30 PM Resident 13's wheelchair was observed to be dirty with crumbs on the bottom cushion. [The wheelchair did not appear to be cleaned as documented in the July 2024 TARS.]

Resident 13's July 2024 TARS revealed her/his wheelchair was to be cleaned monthly and as needed. The task was documented as completed on 7/26/24.

The 4/30/24 Resident Council Notes revealed the residents felt their wheelchairs were either getting dirty or already very dirty and requested the wheelchairs be on a cleaning schedule.

The 6/25/24 Resident Council Notes revealed the residents asked to have their wheelchairs cleaned and to start a cleaning schedule.

On 7/24/24 at 10:46 Staff 28 (Agency CNA) verified Resident 13's wheelchair had crumbs over the bottom cushion and a small brown smudge mark to the bottom cushion.

On 7/24/24 at 10:50 AM Resident 13 stated the facility does not keep her/his wheelchair clean and it was currently dirty.

On 7/26/24 at 12:30 PM Staff 29 (LPN) and Staff 15 (LPN Resident Care Manager) verified the wheelchair was dirty. Staff 29 verified she documented the wheelchair was cleaned although she had not cleaned it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 385121