Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Friendship Manor Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with right hemiparesis, hemiplegia, and epilepsy wore a protective helmet when out of bed and in a wheelchair, but the record had no order for the device and no TAR documentation showing skin integrity monitoring. Staff confirmed the helmet was used routinely and the DON stated skin should have been monitored for pressure injury related to the device.
PICC Line Dressing Not Changed as Ordered: A resident with chronic osteomyelitis had a PICC line order for dressing changes every 7 days with measurement of the external catheter length and upper arm circumference. Staff observed the resident with an IV line in the upper arm, but the resident did not know when the dressing was last changed. MAR review showed the PICC external catheter was not measured and the dressing was not changed as ordered, and both an LPN and the DON stated the PICC care should have been done.
A resident with a kidney transplant and immunodeficiency received an incorrect dose of tacrolimus due to a transcription error in the EHR, which was not identified by the pharmacy consultant during an Interim MRR. Additionally, the facility failed to act on recommendations for lab tests to monitor the resident's tacrolimus levels, missing opportunities to detect the dosage error.
A resident with a kidney transplant and immunodeficiency was given an incorrect dose of tacrolimus due to a charting error, receiving 25mg daily instead of the prescribed 2.5mg. This error occurred for 29 out of 37 days, as identified through record reviews and staff interviews.
A CNA with an expired license continued to provide direct care to residents, despite a position change to Direct Care Partner (DCP), which does not involve patient care. The lapse occurred due to the DSD's unawareness of the cancellation of a COVID waiver allowing CNAs to work without a license. The DON and ADM acknowledged the risk of harm to residents from unlicensed staff providing care.
The facility failed to ensure a licensed nurse completed mandatory annual abuse training after returning from leave, as required by Federal regulations. The nurse had last attended training in December 2022, but upon returning to work in February 2024, there was no documentation of updated training. This deficiency was identified during an unannounced visit following an abuse complaint, highlighting a risk to resident safety due to potential unpreparedness of staff to handle abuse situations.
Failure to Monitor Skin Integrity With Protective Helmet Use
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not implemented when Resident 2 wore a protective helmet without documented monitoring for skin integrity. Resident 2 was readmitted with diagnoses including right hemiparesis, hemiplegia, and epilepsy. During observation, Resident 2 was seated in a wheelchair wearing the helmet and was non-verbal but able to answer questions by nodding her head. The nursing readmission record did not document the helmet as a medical device used for the resident, and the Treatment Administration Record did not include monitoring to assess whether the skin was being affected by the helmet. Interviews with nursing staff and CNAs confirmed that Resident 2 wore the helmet when out of bed and in the wheelchair, and that staff placed it on when she was up and removed it when she returned to bed. A joint record review with LN 2 found no order for the helmet and no documentation in the TAR showing that skin integrity was assessed and monitored during helmet use. The DON stated there should have been an order for the helmet and staff should have been monitoring the skin to ensure there were no pressure injury from its use. The facility procedure for prevention of pressure injuries stated that medical devices should be reviewed and selected to minimize tissue damage and that skin changes should be monitored, reported, and documented.
PICC Line Dressing Not Changed or Assessed as Ordered
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids for a resident when needed was not met when the facility failed to assess and change a PICC line dressing for Resident 40. Resident 40 was admitted with diagnoses that included chronic osteomyelitis of the left ankle and foot, and the physician’s order dated 6/14/25 directed staff to change the PICC line dressing every 7 days and measure the external length of the catheter and upper arm circumference. On 7/21/25, Resident 40 was observed in his room with an IV line on his right upper arm. He refused to show the IV dressing and stated he did not remember when the dressing was last changed. A review of the July 2025 MAR showed that on 7/12/25 the PICC line external catheter was not measured and the dressing was not changed as ordered. LN 6 stated that PICC line care was not done and should have been done, and the DON stated that Resident 40’s PICC line dressing was not changed but should have been. The facility policy titled Central Venous Catheter Care and Dressing Changes, dated October 2024, required dressing changes every 7 days and, for PICCs, measurement of arm circumference.
Failure to Identify Medication Irregularities and Conduct Lab Monitoring
Penalty
Summary
The facility failed to ensure that a licensed pharmacist identified irregularities during a medication regimen review for a resident who was admitted with a kidney transplant and immunodeficiency. The resident's tacrolimus dosage was incorrectly entered into the Electronic Health Record (EHR) as 5 mg instead of the prescribed 0.5 mg. This error was not identified by the pharmacy consultant during the Interim Medication Regimen Review (MRR), as the After Visit Summary was not available in the resident's chart at the time of review. Consequently, the resident received an excessive dose of tacrolimus throughout their stay at the facility. Additionally, the facility did not act upon the pharmacy consultant's recommendation to obtain laboratory tests to monitor the resident's tacrolimus levels. Despite recommendations made on two separate occasions, the necessary lab work was not conducted, which could have identified the irregularity in the medication dosage. The Director of Nursing expressed an expectation for the pharmacy to identify such irregularities and emphasized the importance of completing pharmacy recommendations to prevent harm to residents.
Significant Medication Error Due to Incorrect Dosage Entry
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the prescribed dose of tacrolimus was not administered according to the physician's orders. The resident, who had a history of kidney transplant and immunodeficiency due to drugs, was admitted with instructions to take tacrolimus 0.5mg capsules, totaling 2.5mg per day. However, the medication was incorrectly entered into the resident's chart as 5mg, resulting in the administration of 25mg per day for 29 out of 37 days during the resident's stay. This error was identified during a record review and confirmed through interviews with the Director of Staff Development and the Medical Director. The Medical Director emphasized the importance of administering the correct dose to prevent potential adverse effects, such as infection. The facility's policy on administering medications, which mandates safe and timely administration as prescribed, was not followed, leading to this significant medication error.
Unlicensed CNA Providing Direct Care
Penalty
Summary
The facility failed to ensure that one of its nursing staff, a Certified Nursing Assistant (CNA), had the required continuing education and state certifications necessary for working with the resident population. This deficiency was identified during an unannounced visit following a Facility Reported Incident. The CNA in question had an expired license but continued to work full-time, providing care to residents. The lapse in checking licenses was attributed to the Director of Staff Development (DSD), who was unaware of the cancellation of the COVID blanket waiver that previously allowed CNAs to work without a license due to delays in issuing licenses. The CNA's personnel file indicated that their license had expired, and despite a position change from CNA to Direct Care Partner (DCP), they continued to perform CNA duties, which involved direct patient care. The Director of Nursing (DON) clarified that a DCP's role does not include patient care tasks, yet the CNA was utilized as a CNA until the deficiency was discovered. Interviews with the DON and Administrator confirmed that having unlicensed staff providing direct care could potentially harm residents due to insufficient training for the required care tasks.
Failure to Ensure Mandatory Abuse Training for Staff
Penalty
Summary
The facility failed to ensure that a licensed nurse, LN 1, completed the annual Federal mandatory abuse training, which is a requirement for all staff. LN 1 was hired in May 2018 and had last attended an in-person abuse training session in December 2022. However, after returning from a leave of absence from June 2023 to February 2024, there was no documentation to show that LN 1 had completed the required abuse training upon returning to work. This oversight was confirmed by the Director of Staff Development (DSD), who acknowledged that LN 1 should have been provided with the training immediately upon return. The deficiency was identified during an unannounced visit to the facility in response to a complaint alleging abuse. Interviews with staff, including a certified nursing assistant and the Director of Nursing (DON), confirmed that abuse training is mandatory and should be conducted at least annually. The facility's policy mandates that all employees attend resident rights and abuse prevention training before having any resident contact. The lack of training for LN 1 put all residents at risk for potential abuse, as staff may not be adequately prepared to recognize and handle situations involving abuse, neglect, or isolation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near National City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paradise Valley Health Care | 0.1 mi | ★★★★★ | 2 | 0 |
| Castle Manor Nursing & Rehabilitation Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Reo Vista Healthcare Center | 1.4 mi | ★★★★★ | 6 | 0 |
| Hillcrest Manor Sanitarium | 1.6 mi | ★★★★★ | 20 | 0 |
| National City Post Acute | 1.8 mi | ★★★★★ | 25 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.