Inspection Report — Dec 19, 2025
Complaint Investigation
Citations: 2
Date: Dec 19, 2025
Visit Reason
The inspection was conducted based on recertification and complaint surveys from 12/11/2025 to 12/19/2025 to investigate allegations related to accident hazards, inadequate supervision, and medication errors at The Friendly Home nursing facility.
Complaint Details
The complaint investigation (#2619460 and #2691821) revealed issues with accident hazards, supervision, and medication errors. The facility was disputing the citation related to accident hazards. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure a safe environment free from accident hazards and adequate supervision for residents, including unsecured alcohol possession, unsafe transfer bar conditions, and elopement due to a malfunctioning door. Additionally, the facility failed to prevent significant medication errors for three residents, including improper insulin administration and failure to resume medications after hospitalization.
Citations (2)
Nursing home area was not free from accident hazards and did not provide adequate supervision to prevent accidents, including unsecured alcohol at bedside, unsafe transfer bar gaps, and elopement due to malfunctioning door.
Residents were not free from significant medication errors, including insulin administration outside prescribed parameters and failure to administer medications after hospital discharge.
Report Facts
Residents reviewed: 10
Residents with deficiencies: 3
Residents reviewed: 6
Residents with medication errors: 3
Gap size: 4
Insulin units: 6
Insulin units: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Documented Resident #126's exit seeking behaviors |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Documented Resident #126 pacing hallways and interrupting medication pass |
| Licensed Practical Nurse #11 | Licensed Practical Nurse | Documented Resident #126 was not on the unit during elopement |
| Concierge #1 | Concierge | Reported hearing alarm and deactivating it allowing Resident #126 to elope |
| Registered Nurse Manager #5 | Registered Nurse Manager | Interviewed regarding door malfunction and supervision prior to elopement |
| Director of Health Services | Director of Health Services | Interviewed regarding door issues, alcohol possession, and transfer bar safety |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Aware of Resident #85 having alcohol in room |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Unaware of alcohol possession policy and would confiscate alcohol if found |
| Licensed Practical Nurse Clinical Coordinator #3 | Licensed Practical Nurse Clinical Coordinator | Aware of alcohol possession and wandering residents on unit |
| Registered Nurse Manager #3 | Registered Nurse Manager | Observed transfer bar gap and described transfer bar safety checks |
| Director of Building Services #1 | Director of Building Services | Described maintenance work orders and transfer bar installation and checks |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Described transfer bar safety checks and documentation |
| Licensed Practical Nurse Clinical Coordinator #1 | Licensed Practical Nurse Clinical Coordinator | Interviewed about medication resumption after hospital discharge |
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed about medication errors and insulin administration |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Documented Resident #154's return from hospital |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Interviewed about blood glucose checks before insulin administration |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about timing of blood glucose checks before insulin |
| Registered Nurse Manager #4 | Registered Nurse Manager | Interviewed about nursing staff expectations for insulin administration |
Inspection Report — Jan 30, 2024
Capacity: 60
Citations: 1
Date: Jan 30, 2024
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm.
Findings
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm.
Citations (1)
Reporting - national health safety network
Inspection Report — Jan 22, 2024
Capacity: 60
Citations: 1
Date: Jan 22, 2024
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm.
Findings
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm.
Citations (1)
Reporting - national health safety network
Inspection Report — Jan 8, 2024
Capacity: 60
Citations: 1
Date: Jan 8, 2024
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm.
Findings
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm.
Citations (1)
Reporting - national health safety network
Inspection Report — Jan 2, 2024
Capacity: 60
Citations: 1
Date: Jan 2, 2024
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm.
Findings
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm.
Citations (1)
Reporting - national health safety network
Inspection Report — Dec 26, 2023
Annual Inspection
Capacity: 60
Citations: 10
Date: Dec 26, 2023
Visit Reason
Multiple Level 2 deficiencies in standard health and life safety code citations including abuse/neglect policies, equipment, infection prevention, and corridor widths. All corrected as of early 2024.
Findings
Multiple Level 2 deficiencies in standard health and life safety code citations including abuse/neglect policies, equipment, infection prevention, and corridor widths. All corrected as of early 2024.
Citations (10)
Develop/implement abuse/neglect policies
Essential equipment, safe operating condition
Increase/prevent decrease in rom/mobility
Infection prevention & control
Infection preventionist qualifications/role
Label/store drugs and biologicals
Tube feeding mgmt/restore eating skills
Aisle, corridor, or ramp width
Corridor - doors
Electrical equipment - testing and maintenanc
Inspection Report — Oct 30, 2023
Capacity: 60
Citations: 1
Date: Oct 30, 2023
Visit Reason
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm.
Findings
One Level 2 deficiency related to reporting to the national health safety network, widespread scope, no actual harm.
Citations (1)
Reporting - national health safety network
Inspection Report — Mar 2, 2022
Complaint Investigation
Capacity: 60
Citations: 7
Date: Mar 2, 2022
Visit Reason
Multiple Level 1 and 2 deficiencies related to care planning, accident hazards, transfer notices, resident return, and construction standards. All corrected by April 2022.
Findings
Multiple Level 1 and 2 deficiencies related to care planning, accident hazards, transfer notices, resident return, and construction standards. All corrected by April 2022.
Citations (7)
Develop/implement comprehensive care plan
Free of accident hazards/supervision/devices
Notice requirements before transfer/discharge
Permitting residents to return to facility
Standards of construction for new existing nh
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Inspection Report — Sep 17, 2019
Annual Inspection
Citations: 3
Date: Sep 17, 2019
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in developing complete, person-centered care plans for residents, maintaining appropriate range of motion devices, and implementing proper infection prevention and control practices. Deficiencies involved failure to include antidepressant use and non-healing wounds in care plans, lack of palm protectors for a resident with severe hand contracture, and improper hand hygiene during wound care.
Citations (3)
Failure to develop and implement a complete care plan that meets all the resident's needs, including measurable objectives and interventions for antidepressant use and non-healing wounds.
Failure to provide appropriate care to maintain or improve range of motion, specifically not providing a palm protector for a resident with severe hand contracture.
Failure to provide and implement an infection prevention and control program, including improper hand hygiene by staff during wound care.
Report Facts
Residents reviewed for unnecessary medications: 7
Residents reviewed for skin conditions: 8
Residents reviewed for positioning: 5
Wound size: 3
Wound size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Manager #1 | Registered Nurse Manager | Responsible for developing care plans; acknowledged failure to develop care plan for antidepressant use |
| RN Manager #2 | Registered Nurse Manager | Stated non-healing wound should be addressed in care plan |
| Director of Nursing | Director of Nursing | Stated non-healing wound should be addressed in care plan |
| CNA | Certified Nursing Assistant | Reported missing splints and difficulty with resident's hand care |
| Occupational Therapist | Occupational Therapist | Completed resident evaluation and expected use of palm protector |
| Director of Therapy | Director of Therapy | Expected staff to follow care card instructions and notify therapy of missing equipment |
| RN Assistant Manager | Registered Nurse Assistant Manager | Explained therapy orders and documentation process for splints |
| LPN | Licensed Practical Nurse | Unaware of resident's splints or palm protectors |
| LPN | Licensed Practical Nurse | Observed not washing hands or using sanitizer during wound care |
| Infection Control Nurse | Infection Control Nurse | Explained hand hygiene expectations after wound dressing changes |
| RN Manager | Registered Nurse Manager | Stated expectations for glove changes and hand hygiene during wound care |
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