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Complaint Investigation

Friendship Haven Healthcare And Rehabilitation Cen

Inspection Date: September 4, 2025
Total Violations 2
Facility ID 675744
Location Friendswood, TX
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Inspection Findings

F-Tag F0627

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

facility had gone above and beyond to accommodate CR # 2's RP, and there was nothing the facility could have done differently because the situation was getting worst.An attempt was made on 09/03/25 at 3:00pm to have an interview with CR #2's physician at the time of discharged , but he refused to communicate without his lawyer and would not comment on CR #2 case because it was in court. An attempt was made to contact the hospital social worker but there was no answer. There was no way to leave message. Record

review of Facility's policy titled Discharging the Resident dated 2001 and revised 2016 revealed no evidence of discharge after an appeal process.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Friendship Haven Healthcare and Rehabilitation Cen

1500 Sunset Dr Friendswood, TX 77546

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)

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F-Tag F0644

Resident Assessment and Care Planning Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 REDACTED]. Her diagnoses included- Profound intellectual disabilities, major depressive disorder, anxiety disorder, bilateral primary osteoarthritis of knee, (tissue wears down) prediabetes, gastric ulcer, anemia (Low Blood count), age-related osteoporosis, and end stage renal diseaseRecord review of Resident #1's PASRR evaluation dated 12/27/25 indicated Resident #1 was positive for Intellectual disability.Record

review of PCSP dated 01/29/25 indicated there was a recommendation for Resident #1 to receive a customized manual wheelchair.Record review of Resident #1's clinical records revealed no evidence of the NFSS form. During an interview on 09/03/25 at 1:00PM, the Administrator said MDS Coordinator A was responsible for doing PASRR. She provided During an interview with MDS Coordinator A on 09/03/25 at 1:30PM, she said Resident #1's NFSS was not submitted because at the time of the meeting and recommendation, Resident #1 had no payer source and was not aware that she could submit the NFSS without being approved for Medicaid. She said failure to submit the NFSS, as required, may prevent residents from receiving services needed for their wellbeing. Policy on PASRR submission was requested

on 09/04/25 from MDS Coordinator but not provided prior to exit on 09/04/25

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📋 Inspection Summary

Friendship Haven Healthcare and Rehabilitation Cen in Friendswood, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Friendswood, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Friendship Haven Healthcare and Rehabilitation Cen or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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