Deficiencies (last 5 years)
Deficiencies (over 5 years)
16.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
376% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
88% occupied
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 111
Capacity: 126
Deficiencies: 11
Date: Dec 19, 2025
Visit Reason
A recertification and complaint surveys were conducted at The Friendly Home from 12/16/2025 through 12/19/2025 to determine compliance with federal and state regulations including Long Term Care Facilities, State licensure, and emergency preparedness.
Complaint Details
The survey included complaint investigations with intake ID reference numbers 2676813, 2621832, 2603983, and 2594543. Deficiencies were identified related to falls, medication administration, trauma-informed care, and infection control.
Findings
Multiple deficiencies were identified related to professional standards of care, quality of care, bowel/bladder management, behavioral health services, drug regimen review, infection control, and life safety code compliance. The facility failed to meet several regulatory requirements, including failure to follow physician orders, inadequate documentation, and failure to provide timely interventions. A Plan of Correction (POC) was submitted addressing these issues.
Deficiencies (11)
Failure to meet professional standards of quality in services provided, including failure to ensure use of gait-sleeves and booties for residents at risk of falls.
Failure to ensure quality of care related to bowel protocol and management for residents with constipation.
Failure to ensure proper care for residents with urinary incontinence and catheter care.
Failure to maintain acceptable nutritional status and hydration for residents.
Failure to provide trauma-informed care for residents with history of trauma.
Failure to provide adequate behavioral health services and monitoring for residents with schizophrenia and dementia.
Failure to properly review and monitor drug regimens, including medication errors and unnecessary drugs.
Failure to provide timely and accurate laboratory and medical record documentation.
Failure to maintain infection prevention and control program including antibiotic stewardship.
Failure to maintain resident-identifiable information and medical records accurately and confidentially.
Failure to maintain life safety code compliance related to oxygen cylinder storage.
Report Facts
Census: 111
Total Capacity: 126
Deficiencies cited: 12
Dates of survey: 12/16/2025 through 12/19/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam J. Sheehan | Laboratory Director or Provider/Supplier Representative | Signed the report on 1/12/2026 |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 19, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality and practices at The Friendly Home nursing facility, including review of incidents, resident care, and adherence to physician orders.
Findings
The facility failed to ensure services met professional standards related to three residents: Resident #32 who suffered a fall resulting in a femur fracture and lacked proper orthostatic blood pressure monitoring and follow-up appointment scheduling; Resident #88 who did not consistently have bilateral off-loading foot booties applied as ordered; and Resident #111 who was transferred without wearing prescribed geri-sleeves. Staff interviews confirmed these deficiencies and lack of adherence to physician orders.
Deficiencies (3)
Failure to monitor orthostatic blood pressure and schedule follow-up appointment for Resident #32 after a fall resulting in femur fracture.
Failure to apply bilateral off-loading foot booties as ordered for Resident #88 on multiple dates.
Failure to apply geri-sleeves during transfer for Resident #111 as ordered.
Report Facts
Dates booties not applied: 5
Brief Interview for Mental Status score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Physician | Authored progress note regarding orthostatic blood pressure monitoring for Resident #32 |
| Staff A | Licensed Practical Nurse (LPN) | Acknowledged physician's note and lack of follow-up appointment scheduling for Resident #32 |
| Staff B | Scheduler | Responsible for making appointments, unaware of Resident #32's follow-up appointment until surveyor intervention |
| Director of Nursing Services | Director of Nursing Services (DNS) | Unable to provide evidence that Resident #32 received services meeting professional standards and that staff followed physician orders for Resident #111 |
| Staff C | Licensed Practical Nurse (LPN) | Acknowledged Resident #88 did not have booties on during observation |
| Staff D | Nursing Assistant | Observed transferring Resident #111 without geri-sleeves as ordered |
| Nurse Practitioner | Nurse Practitioner | Expected staff to follow physician's order regarding booties for Resident #88 |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Dec 19, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with professional standards of quality, care, medication management, and regulatory requirements for The Friendly Home nursing facility.
Findings
The facility was found deficient in multiple areas including failure to ensure professional standards of care related to fall prevention and follow-up, bowel protocol implementation, catheter care, nutritional monitoring, trauma-informed care, behavioral health services, medication regimen review, medication error prevention, laboratory result notification, and accurate resident record documentation.
Deficiencies (12)
Failure to ensure professional standards of quality and practices related to fall prevention and follow-up care for Resident ID #32, including lack of orthostatic blood pressure monitoring and missed follow-up appointments.
Failure to provide care according to physician orders for off-loading foot booties for Resident ID #88, with repeated missed applications.
Failure to maintain foley catheter tubing below bladder level for Resident ID #9, increasing risk of infection.
Failure to provide adequate nutritional care for Resident ID #120, resulting in significant weight loss of 9.06% over two weeks without appropriate intervention or notification.
Failure to provide trauma-informed care and incorporate trauma history into care planning for Resident ID #11.
Failure to provide necessary behavioral health care and psychiatric consultation for Resident ID #46 with schizophrenia, including discontinuation of PRN medication without replacement.
Failure to act upon irregularities identified by pharmacist during medication regimen review for Resident ID #6, specifically regarding antibiotic dosing.
Failure to ensure resident's drug regimen is free from unnecessary drugs, including Resident ID #6 receiving excess antibiotic doses.
Failure to ensure residents are free from significant medication errors, including missed antibiotic doses for Resident ID #33 and missed anticoagulant doses for Residents ID #46 and #84.
Failure to promptly notify ordering practitioner of laboratory results for Resident ID #84, with PT/INR results reviewed the day after blood draw.
Failure to maintain complete and accurate resident records, including inaccurate documentation of foley catheter leg bag changes for Resident ID #9, missed application of off-loading booties for Resident ID #88, and missed application of geri-sleeves and knee sleeve for Resident ID #111.
Failure to implement an antibiotic stewardship program that monitors antibiotic use and ensures appropriate antibiotic prescribing for Residents ID #6 and #33.
Report Facts
Weight loss percentage: 9.06
Missed antibiotic doses: 3
Excess antibiotic doses: 7
Missed anticoagulant doses: 4
Missed anticoagulant doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Acknowledged failure to monitor orthostatic blood pressure and follow-up appointment scheduling for Resident ID #32; acknowledged foley catheter tubing not maintained below bladder level for Resident ID #9. |
| Staff B | Scheduler | Revealed unawareness of follow-up appointment scheduling for Resident ID #32 until surveyor intervention. |
| Director of Nursing Services | Unable to provide evidence of professional standards of care for multiple deficiencies including Resident ID #32, bowel protocol failures, medication errors, trauma-informed care, and behavioral health services. | |
| Staff C | Licensed Practical Nurse | Acknowledged failure to apply off-loading booties for Resident ID #88 and failure to apply geri-sleeves and knee sleeve for Resident ID #111. |
| Staff D | Nursing Assistant | Acknowledged failure to apply geri-sleeves during transfer for Resident ID #111. |
| Staff E | Licensed Practical Nurse | Acknowledged behavioral issues of Resident ID #46 and lack of PRN medication; acknowledged failure to apply geri-sleeves and knee sleeve for Resident ID #111. |
| Staff F | Physician | Authored progress notes regarding Resident ID #32; unaware of Eliquis refusal by Resident ID #46; expected timely review of PT/INR labs. |
| Staff G | Physician | Expected PT/INR bloodwork to be reviewed same day and reported immediately for Resident ID #84. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
The inspection was conducted following a complaint related to a resident who eloped from the facility unsupervised, raising concerns about adequate supervision and safety measures.
Complaint Details
The complaint investigation substantiated that the facility failed to provide adequate supervision for Resident ID #1, who eloped on 7/31/2025 and was found by police approximately 1.5 miles from the facility. The facility was unaware of the elopement for about 1.5 hours and failed to complete required risk assessments after prior incidents.
Findings
The facility failed to ensure adequate supervision for a cognitively impaired resident who eloped from the facility without his ordered helmet and was found approximately 1.5 miles away. The facility did not complete required elopement risk assessments or implement interventions following prior incidents, placing the resident at immediate jeopardy.
Deficiencies (1)
Failure to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, resulting in a resident eloping unsupervised.
Report Facts
Distance resident eloped: 1.5
Time resident eloped before facility awareness: 1.5
Date of resident elopement: Jul 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician | Reported last seeing the resident at approximately 4:55 PM on 7/31/2025 and delivering medications |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 22, 2025
Visit Reason
The inspection was conducted in response to a community reported complaint alleging that Resident ID #1 did not receive prescribed pain medication as ordered.
Complaint Details
The complaint was community reported to the Rhode Island Department of Health on 5/20/2025 alleging medication administration errors for Resident ID #1. The complaint was substantiated based on record reviews and staff interviews.
Findings
The facility failed to ensure that services met professional standards of quality related to medication administration for Resident ID #1. Specifically, the resident did not receive the Buprenorphine patch as ordered on 5/15/2025, and was administered a lower dose of Dilaudid than prescribed on multiple occasions.
Deficiencies (2)
Failure to administer Buprenorphine patch as ordered on 5/15/2025; patch was signed off as administered but was not available.
Resident received 2 mg of Dilaudid instead of the prescribed 4 mg on 5/21/2025 and 5/22/2025.
Report Facts
Medication dosage: 5
Medication dosage: 4
Medication dosage: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Acknowledged signing off Buprenorphine patch as administered when it was not |
| Staff C | Licensed Practical Nurse | Acknowledged administering 2 mg of Dilaudid instead of 4 mg on 5/21/2025 and 5/22/2025 |
| Director of Nursing Services | Acknowledged Resident ID #1 did not receive Buprenorphine as ordered and expected proper medication administration | |
| Staff A | Unit Manager, Registered Nurse | Indicated Buprenorphine patch was not available on 5/15/2025 despite being signed off as administered |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 31, 2025
Visit Reason
The inspection was conducted following a reported incident regarding missing narcotic patches delivered to the facility on 3/25/2025, with concerns about improper storage and handling of controlled medications.
Complaint Details
The complaint investigation was triggered by a report submitted to the Rhode Island Department of Health on 3/27/2025 regarding missing narcotic patches delivered on 3/25/2025. The nurse on duty did not recall receiving the medication, and a Nursing Assistant improperly signed for the delivery. The Director of Nursing acknowledged the improper handling and documentation.
Findings
The facility failed to store drugs and biologicals according to accepted professional principles, specifically failing to document receipt of controlled medications properly. A Nursing Assistant improperly signed for controlled medication delivery, which was not recorded in the controlled substance count book, and nursing staff did not recall receiving the medication.
Deficiencies (1)
Failure to store drugs and biologicals in accordance with professional principles, including improper receipt and documentation of controlled medications.
Report Facts
Controlled medication patches delivered: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nursing Assistant | Signed for the controlled medication delivery on 3/25/2025 but acknowledged signing improperly. |
| Staff B | Registered Nurse | Nurse on duty on 3/25/2025 who did not recall receiving the medication and stated NAs should not sign for medications. |
| Director of Nursing Services | Acknowledged that the Nursing Assistant improperly signed for the controlled medication and that it was not documented in the narcotic book. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 30, 2024
Visit Reason
The inspection was conducted in response to a community reported complaint alleging failure to notify the resident's representative of significant changes in medical treatment and concerns about the care provided to Resident ID #1.
Complaint Details
The complaint alleged that the resident was started on several medications, had a foley catheter inserted, and the facility failed to notify the resident's representative. The complainant also raised concerns about care quality, including unnecessary medications and administration of a laxative during diarrhea and dehydration. The resident was removed from the facility's care.
Findings
The facility failed to notify the resident's representative of multiple changes in medical treatment including new medications and insertion of a foley catheter. Additionally, the facility failed to follow physician orders regarding administration of blood pressure medication and administered a laxative to a resident with diarrhea and an active C. diff infection.
Deficiencies (2)
Failure to notify the resident's representative of significant changes in medical treatment including new medications and insertion of a foley catheter.
Failure to provide treatment and care according to physician orders, including administering blood pressure medication outside of ordered parameters and administering a laxative to a resident with diarrhea and active C. diff infection.
Report Facts
Medication administration dates outside parameters: 7
Senna Plus administration duration: 55
Medication dosages: 25
Medication dosages: 25
Medication dosages: 5
Antibiotic dosage: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse, Staff A | Interviewed and stated it is facility policy to notify resident's representative of changes in medical status. | |
| Nurse Practitioner (APRN) | Interviewed and stated facility responsible for updating resident's representative; unaware of medical power of attorney during assessments; unaware of Hydralazine administration outside parameters; unaware of Senna Plus administration during C. diff infection. | |
| Assistant Director of Nursing | Interviewed and unable to provide evidence that resident's representative was notified of medical changes; confirmed Senna Plus was given during active C. diff infection and diarrhea. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 4, 2024
Visit Reason
A recertification and complaint surveys were conducted at Friendly Home, Inc. from 9/30/2024 through 10/4/2024 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities, including a state licensing and emergency preparedness survey.
Complaint Details
Complaint surveys were part of the visit, but substantiation status is not explicitly stated in the report.
Findings
Deficiencies were identified related to professional standards of care, quality of care, treatment and services to prevent pressure ulcers, nursing services competencies, infection prevention and control, food safety, and facility assessment. The facility failed to ensure residents received treatment and care in accordance with physician orders and professional standards, including wound care, offloading heels, blood sugar monitoring, and infection control.
Deficiencies (6)
Failure to ensure residents receive treatment and care in accordance with physician orders for offloading heels and glucose monitoring.
Failure to ensure residents receive treatment and care in accordance with professional standards for wound care and skin integrity.
Failure to ensure nursing staff have appropriate competencies and skills to provide nursing and related services.
Failure to maintain infection prevention and control program to prevent transmission of communicable diseases.
Failure to store, prepare, distribute, and serve food in accordance with professional standards for food safety.
Failure to conduct and document a facility-wide assessment to determine resources necessary to care for residents.
Report Facts
Dates of blood sugar levels: 12
Number of residents reviewed for pressure ulcers: 6
Number of residents with wound care orders reviewed: 4
Number of residents with edema reviewed: 3
Number of residents with infection control issues reviewed: 2
Number of residents with PICC line care reviewed: 1
Number of residents with pressure ulcers reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Picard | Administrator | Signed the report and plan of correction documents. |
| Staff C | Registered Nurse involved in wound care and documentation issues. | |
| Staff D | Licensed Practical Nurse | Acknowledged edema and wound care observations. |
| Staff F | Licensed Practical Nurse | Observed failing to remove gloves and perform hand hygiene during wound care. |
| Director of Nursing Services (DNS) | Director of Nursing Services | Unable to explain why physician orders were not followed; responsible for executing action plans. |
| Staff G | Registered Nurse | Involved in wound care and competency training. |
| Staff E | Licensed Practical Nurse | Acknowledged resident edema and lack of documentation. |
| Staff Development Coordinator (SDC) | Staff Development Coordinator | Observed wound care dressing application and training. |
| Food Service Director (FSD) | Food Service Director | Acknowledged food safety observations and staff compliance issues. |
Inspection Report
Routine
Deficiencies: 11
Date: Oct 4, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, infection control, wound care, medication administration, staff competencies, food safety, and facility-wide resource assessment at The Friendly Home nursing facility.
Findings
The facility failed to ensure residents received care according to physician orders, including offloading heels, glucose monitoring, wound care, and PICC line management. Deficiencies were noted in staff competencies, infection control practices, food safety, and facility-wide resource assessment documentation.
Deficiencies (11)
Failure to follow physician's orders for offloading heels to prevent pressure injury for Resident ID #73.
Failure to report elevated blood sugar levels to provider as ordered for Resident ID #85.
Failure to complete wound care treatments and body audits as ordered for Resident ID #273.
Failure to notify provider and document edema and interventions for Resident ID #64.
Failure to notify provider and document skin tear treatment for Resident ID #90.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for Residents ID #35 and #103.
Failure to meet professional standards in PICC line care and intravenous antibiotic administration for Resident ID #273.
Failure to ensure nursing staff competencies for wound VAC, PICC line care, and IV medication administration.
Failure to store, prepare, distribute, and serve food in accordance with professional standards, including improper food temperatures, lack of beard restraints, and improper storage of staff lunches.
Failure to conduct and document a comprehensive facility-wide assessment of resources necessary for resident care.
Failure to maintain infection prevention and control program, including improper contact precautions and wound care practices for residents with MRSA and VRE.
Report Facts
Blood sugar levels: 346
BIMS score: 7
BIMS score: 12
Wound dressing size: 3
Wound dressing size: 1.5
Dried blood area: 144
Date of survey completion: Oct 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Acknowledged failure to offload heels per physician's order for Resident ID #73 |
| Director of Nursing Services | DNS | Unable to explain failure to follow physician orders and acknowledged expectations for care |
| Staff C | Registered Nurse | Failed to complete wound care treatments and PICC line care as ordered |
| Staff D | Licensed Practical Nurse | Unaware of edema and skin tear, no documentation or provider notification |
| Staff E | Licensed Practical Nurse | Acknowledged resident's heels were resting on mattress, not offloaded |
| Staff F | Licensed Practical Nurse | Failed to follow wound care infection control procedures and PICC line dressing change |
| Staff G | Registered Nurse | Lack of documented competency for wound VAC, PICC line, and IV medication administration |
| Staff H | Licensed Practical Nurse | Lack of documented competency for wound VAC, PICC line, and IV medication administration |
| Staff I | Dietary Aide | Observed without beard restraint during food service |
| Staff Development Coordinator | SDC | Observed improper wound care practices and acknowledged failures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 22, 2024
Visit Reason
The inspection was conducted in response to a community reported complaint alleging neglect of Resident ID #1 related to wounds and a change in mental status, including failure to provide appropriate skin care.
Complaint Details
The complaint was substantiated, alleging neglect due to missed wound care and skin assessments resulting in hospitalization for wounds and mental status change of Resident ID #1.
Findings
The facility failed to ensure that Resident ID #1 received treatment and care according to professional standards for skin assessment and weekly body audits, missing documentation for 7 consecutive weeks. The resident had worsening wounds including non-pressure wounds and a stage 2 pressure wound, with the Director of Nursing Services acknowledging the missed weekly skin audits.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders and professional standards for skin assessment for Resident ID #1.
Report Facts
Weeks of missed skin audits: 7
Wound measurements: 9
Wound measurements: 2.2
Wound measurements: 0.1
Wound measurements: 1.4
Wound measurements: 1.2
Wound measurements: 0.1
Wound measurements: 5.4
Wound measurements: 0.4
Wound measurements: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Acknowledged that the weekly skin audits tasks were not completed as ordered during surveyor interviews on 8/21/2024 and 8/22/2024. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 11, 2023
Visit Reason
The inspection was conducted in response to community reported complaints alleging failure to provide a resident with access to medical records, failure to develop and implement baseline care plans within 48 hours of admission, inadequate supervision and assistive devices leading to a resident fall, and failure to ensure nursing assistants were properly licensed.
Complaint Details
The complaint investigation was triggered by community reports received by the Rhode Island Department of Health alleging incomplete medical records provided to a resident's legal representative, failure to develop baseline care plans within 48 hours for multiple residents, a resident fall due to inadequate supervision and assistive devices, and unlicensed nursing assistants providing care independently.
Findings
The facility failed to provide timely access to medical records, did not develop effective baseline care plans for residents within 48 hours of admission, failed to ensure adequate supervision and use of assistive devices resulting in a resident fall with increased pain and functional decline, and allowed unlicensed nursing assistants to provide care independently, placing residents at risk of harm.
Deficiencies (4)
Failed to provide a resident with access to medical records upon oral or written request.
Failed to develop and implement a baseline care plan within 48 hours of admission for 3 residents, lacking physician orders, dietary orders, therapy services, and social services.
Failed to ensure adequate supervision and assistive devices to prevent a fall for 1 resident, resulting in a fall with increased pain and functional decline.
Failed to administer the facility to ensure nursing assistants were licensed, allowing unlicensed nursing assistants to provide care independently for multiple days.
Report Facts
Pages of incomplete medical records initially provided: 96
Days delay in providing complete medical records: 90
Residents reviewed for baseline care plan deficiency: 3
Days Staff A worked independently without license: 26
Days Staff F worked independently without license: 18
Pain level after fall: 7
Pain level before fall: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Unlicensed Nursing Assistant | Assisted resident during fall without gait belt or back brace; worked independently without license for 26 days |
| Staff B | Licensed Practical Nurse | Was present before resident fall but unaware of resident's transfer needs |
| Staff C | Physical Therapist | Provided therapy recommendations for resident transfer and use of assistive devices |
| Staff D | Licensed Practical Nurse, Skilled Unit Manager | Entered physician orders but failed to transcribe back brace order; acknowledged transfer requirements not met |
| Staff E | Advanced Practice Registered Nurse | Resident's provider who expected adherence to therapy recommendations |
| Staff F | Unlicensed Nursing Assistant | Worked independently without license for 18 days |
| Staff G | Licensed Practical Nurse, Staff Development Coordinator | Responsible for competencies of NA trainees; expected temporary licenses before independent work |
| Staff H | Scheduler | Scheduled NA trainees to work independently before receiving temporary licenses |
| Assistant Director of Nursing Services | Aware of medical records requests but had not responded | |
| Director of Nursing Services | Unable to provide evidence of baseline care plans or adherence to therapy recommendations |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 126
Deficiencies: 9
Date: Oct 30, 2023
Visit Reason
A federal recertification survey and complaint investigation was conducted at this nursing home from 10/24/2023 through 10/30/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Complaint Details
The complaint investigation was substantiated with findings of immediate jeopardy related to failure to follow up on diagnostic testing and notify the attending physician, resulting in harm to Resident ID #79 who was hospitalized unresponsive and jaundiced.
Findings
The facility was found to have immediate jeopardy related to failure to ensure residents receive treatment and care in accordance with professional standards, specifically regarding follow-up on diagnostic testing and physician notification. The immediate jeopardy was removed as of 10/29/2023 after corrective actions. Additional deficiencies were cited related to quality of care, skin integrity, physician visits, infection control, and environmental conditions.
Deficiencies (9)
Failure to ensure residents receive treatment and care in accordance with professional standards, including follow-up with diagnostic testing and physician notification for Resident ID #79.
Failure to provide necessary treatment and services to prevent pressure ulcers for Resident ID #81.
Failure to provide appropriate treatment and services for urinary tract infection for Resident ID #31.
Failure to review and sign physician orders timely and ensure continuity of care for multiple residents including Resident ID #79.
Failure to promptly notify practitioner of abnormal ultrasound results for Resident ID #79.
Failure to ensure drug regimen is free from unnecessary drugs for Residents ID #42 and #98.
Failure to provide or obtain radiology and diagnostic services when ordered for Resident ID #79.
Failure to establish and maintain an infection prevention and control program including proper signage, PPE availability, and staff education.
Failure to provide a safe, functional, sanitary, and comfortable environment for residents, including housekeeping and shower room cleanliness.
Report Facts
Deficiencies cited: 9
Resident census: 116
Total capacity: 126
Dates of survey: 2023-10-24 to 2023-10-30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Attending Physician | Named in findings related to failure to follow up on diagnostic testing and sign orders. |
| Staff B | Unit Manager RN | Interviewed regarding resident condition and notification failures. |
| Staff C | Licensed Practical Nurse | Observed applying wound dressing incorrectly. |
| Staff D | Registered Nurse (RN) | Interviewed about resident UTI symptoms and notification. |
| Staff F | Medical Doctor (MD) | Interviewed regarding awareness of ultrasound results. |
| Director of Nursing Services | DNS | Named in multiple findings and responsible for corrective action plans. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Oct 30, 2023
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with healthcare regulations and standards at The Friendly Home nursing facility.
Findings
The facility was found deficient in multiple areas including failure to follow up on diagnostic test results, failure to notify physicians of changes in resident conditions, improper wound care, delayed treatment of urinary tract infections, unsigned physician orders, failure to prevent spread of infection related to MRSA, failure to notify practitioners of abnormal test results, and unsanitary conditions in shower rooms.
Deficiencies (8)
Failure to ensure residents receive treatment and care according to professional standards, including follow-up on diagnostic testing and reporting changes in condition, resulting in immediate jeopardy for Resident ID #79.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for Resident ID #81.
Failure to provide appropriate care for urinary tract infection symptoms for Resident ID #31, resulting in delayed treatment.
Physician failed to review residents' total program of care and failed to sign and date orders for multiple residents.
Failure to ensure residents' drug regimens are free from unnecessary drugs, including administration of antibiotics beyond ordered duration for Residents #42 and #98.
Failure to promptly notify practitioner of abnormal ultrasound results for Resident ID #79.
Failure to follow standard precautions to prevent spread of infection related to MRSA and failure to perform proper wound dressing technique for Residents #42 and #81.
Failure to provide a safe, functional, sanitary, and comfortable environment due to black matter in grout of shower rooms in two wings.
Report Facts
Unsigned physician orders: 2888
Antibiotic administration days: 8
Antibiotic administration days: 11
Stone size: 12
Hemoglobin level: 4.3
Packed red blood cells transfused: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medical Doctor (MD), Attending Physician | Unaware of abnormal ultrasound results and recommendations for Resident #79; failed to sign multiple physician orders |
| Staff B | Unit Manager RN | Unable to provide evidence of notifying Staff A of resident's jaundice and ultrasound results for Resident #79 |
| Staff C | Licensed Practical Nurse | Applied incorrect wound dressing and failed to perform hand hygiene after wound care for Resident #81 |
| Staff D | Registered Nurse | Unable to provide evidence physician was notified of UTI symptoms for Resident #31 |
| Registered Nurse Practitioner (RNP) | Unaware of Resident #31's UTI symptoms and would have ordered urinalysis | |
| Director of Nursing Services (DNS) | Director of Nursing Services | Unable to provide evidence of notifying physician of resident changes and unsigned orders; unable to explain failure in infection control and wound care |
| Assistant Director of Nursing Services (ADNS) | Assistant Director of Nursing Services | Acknowledged extra antibiotic doses administered and unsigned physician orders |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 31, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure a resident's drug regimen was free from unnecessary psychotropic drugs, specifically concerning an as needed psychotropic medication order without a stop date.
Complaint Details
The visit was complaint-related, focusing on substantiation of the complaint that the facility did not limit the use of an as needed psychotropic medication to 14 days as required. The deficiency was substantiated.
Findings
The facility failed to ensure that an as needed psychotropic medication order for Resident ID #4 was limited to 14 days as required. The medication Trazodone was administered beyond 14 days without documented rationale or a stop date, contrary to facility expectations.
Deficiencies (1)
Failure to ensure a resident's drug regimen is free from unnecessary psychotropic drugs; as needed psychotropic medication order not limited to 14 days.
Report Facts
Medication administration dates: 4
Medication dosage: 12.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Interviewed on 5/31/2023 regarding expectations for medication orders and lack of documented rationale for extended use |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 29, 2022
Visit Reason
An off-site desk audit was conducted on November 29, 2022 for all previous deficiencies cited on October 25, 2022 to verify correction.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 122
Capacity: 126
Deficiencies: 2
Date: Oct 25, 2022
Visit Reason
A Recertification, COVID-19 Vaccination Compliance and Complaint Survey was conducted from 10/19/2022 through 10/25/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a complaint investigation related to alleged abuse.
Complaint Details
The complaint investigation was related to allegations of abuse involving Resident ID #164. The facility failed to report the alleged abuse to the State Survey Agency within the required timeframe. The allegation was substantiated based on record review and interviews.
Findings
The facility was found to have failed to ensure that all alleged violations involving abuse were reported immediately as required, specifically for one resident (ID #164). Additionally, the facility failed to ensure residents received treatment and care in accordance with professional standards, including proper blood pressure monitoring for another resident (ID #108).
Deficiencies (2)
Failure to ensure all alleged violations involving abuse were reported immediately as required by regulation.
Failure to ensure residents received treatment and care in accordance with professional standards, specifically regarding blood pressure monitoring and edema management.
Report Facts
Census: 122
Total Capacity: 126
Brief Interview for Mental Status (BIMS) score: 14
Deficiency tags: 2
Inspection Report
Renewal
Deficiencies: 7
Date: Aug 26, 2021
Visit Reason
A Recertification Survey was conducted at Friendly Home from 08/23/2021 through 08/26/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
The facility was determined to be not in compliance with several regulatory requirements, resulting in multiple deficiencies cited related to advance directives, comprehensive care plans, treatment of pressure ulcers, infection control, food safety, and staff training on abuse prevention.
Deficiencies (7)
Facility failed to provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and to formulate an advance directive.
Facility failed to develop and implement comprehensive person-centered care plans for residents, including measurable objectives and timeframes.
Facility failed to provide necessary services to dependent residents unable to carry out activities of daily living.
Facility failed to ensure residents with pressure ulcers receive necessary treatment and services consistent with professional standards of practice.
Facility failed to properly store, prepare, distribute, and serve food under sanitary conditions.
Facility failed to establish and maintain an infection prevention and control program to prevent development and transmission of communicable diseases and infections.
Facility failed to provide training to staff on abuse, neglect, exploitation, and dementia management.
Report Facts
Staff members: 156
Residents reviewed: 20
Residents reviewed for food/snack issues: 8
Residents reviewed for pressure ulcers: 4
Residents reviewed for ADL care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding resident care plans, advance directives, and infection control findings. |
| Staff Nurse F | Staff Nurse | Interviewed regarding resident pressure ulcer and wound care. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding pressure ulcer measurement and care. |
| Food Service Director | Food Service Director | Interviewed regarding food safety and meal service observations. |
| Staff A | Unit Manager | Interviewed regarding resident advance directives and care plans. |
| Staff B | Staff | Interviewed regarding resident orders and advance directives. |
| Staff C | Staff | Interviewed regarding resident advance directives and code status. |
| Staff D | Staff | Interviewed regarding resident edema and care plan. |
| Staff E | Nursing Assistant | Interviewed regarding nail care for residents. |
| Staff I | Nursing Assistant | Interviewed regarding documentation of bedtime snacks. |
| Staff J | Agency Nursing Assistant | Interviewed regarding provision of bedtime snacks. |
| Staff G | Nursing Assistant | Interviewed regarding cleaning and hand hygiene. |
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