Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 The Friendly Home during CMS and state inspections, most recent first.
A resident with recent hospitalization, dysphagia, infection, and nutritional risk experienced severe wt loss of 9.06% in two weeks, with multiple meals documented as no intake or 1-25% consumed. The record did not show that a nutritional supplement was offered when intake was below 50%, and the RD or MD were not notified of the significant wt loss as required by policy.
Failure to Follow Bowel Protocol for Residents With Constipation: The facility did not follow its bowel protocol for 8 residents with no documented BM for multiple days, including one resident with dementia and others with constipation or needing assistance with personal care. Ordered interventions such as prune juice, MOM, Dulcolax suppository, and fleet enema were not given when criteria were met, and the DON acknowledged the bowel protocol was not followed.
A resident with major depressive disorder severe with psychotic features had a trauma screen showing a history of physical and verbal abuse, hurricanes, homelessness, and loss of a sibling, with documentation that the resident was still bothered by these events. The comprehensive care plan did not include trauma-informed interventions to reduce triggers or re-traumatization, and the SW acknowledged the trauma screen was not reflected in the care plan; the DON could not provide evidence of a trauma-informed care plan.
A resident readmitted with PVD and osteomyelitis had a doxycycline order entered as BID, while the hospital continuity of care form listed it as daily. The pharmacist’s MRR flagged the discrepancy and requested provider clarification, but the record did not show that the irregularity was reviewed or acted upon by the provider, and the DON could not provide evidence that the pharmacy consult was reviewed and addressed.
Unnecessary Antibiotic Dosing Discrepancy: A resident with PVD and osteomyelitis received doxycycline in a way that did not match the hospital discharge summary. The discharge summary ordered the antibiotic once daily for 6 doses, but the facility entered it as BID, the MAR showed 13 doses given, and the chart did not show provider clarification after the pharmacist flagged the discrepancy.
Significant medication errors occurred for three residents. One resident with sepsis and dementia did not receive all ordered doses of an antibiotic for cellulitis, and the physician was not notified until the issue was identified by the surveyor. Two residents with orders for anticoagulants had missed doses documented on the MAR, including refusals for Eliquis without evidence the MD was informed and missed Warfarin doses tied to lab-based dosing orders; the DON acknowledged the omissions.
A resident receiving Coumadin for anticoagulation therapy due to atrial fibrillation had PT/INR labs drawn, but the results were not initially reviewed until the following day on two occasions. Staff stated the PT/INR usually results the same day and is reviewed so the provider can be notified and the resident can receive Coumadin that evening; the DON and physician both expected same-day review and immediate reporting.
Incomplete and inaccurate documentation of ordered catheter care and protective devices: A resident with a foley catheter, a resident ordered bilateral off-loading booties, and a resident ordered Geri-sleeves and a right knee sleeve were observed without the ordered items in place, while the TAR documented them as applied or provided. An LPN acknowledged the care was not done as ordered but was charted as completed, and the DON could not explain the inaccurate records.
Failure to monitor antibiotic use and complete antibiotic time outs: The facility’s IPCP did not include an effective antibiotic stewardship process with use protocols and monitoring for two residents. One resident with osteomyelitis had a doxycycline order entered at a different dose and frequency than the hospital discharge instructions, and the antibiotic timeout did not identify the discrepancy. Another resident with sepsis and dementia received fewer cephalexin doses than ordered for cellulitis, and the timeout again did not reflect the five D’s; the MD was not notified of the missed doses until the surveyor identified the issue.
A resident with fall risk and low BP had no documented orthostatic BP checks after a physician’s order, then fell again and sustained a femur fx requiring hospital transfer and surgery; the ordered surgeon follow-up was also not scheduled until the surveyor raised it. In addition, staff did not follow orders for another resident’s off-loading booties and a third resident’s geri-sleeves during transfers, and the DON/DNS could not show that the ordered care was being provided.
A resident with a Foley catheter and flaccid neuropathic bladder was observed multiple times seated in a recliner with the catheter tubing routed upward over the armrest instead of being kept below bladder level. The care plan called for maintaining the Foley below bladder level, and an LPN acknowledged the tubing was not positioned correctly; the DON stated staff would be expected to keep it below bladder level.
A resident with dementia and schizophrenia was repeatedly observed yelling out incoherent words in common areas, the dining room, and the hallway, upsetting other residents who yelled back. The resident had a PRN antipsychotic ordered for severe agitation, but it was discontinued after limited use, and staff reported there was no current PRN medication and no psychiatric consult despite the resident’s ongoing behaviors.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify particular incidents or resident details.
A resident with recent spinal surgery did not receive prescribed pain medications as ordered. The Buprenorphine patch was not available and was falsely documented as administered, while Dilaudid was given at half the prescribed dose on two occasions. Staff interviews and record reviews confirmed these discrepancies, and the DON acknowledged the failure to follow physician orders.
A facility failed to properly store and document controlled medications, as a Nursing Assistant improperly signed for Buprenorphine patches meant for a resident with chronic pain. The patches were not recorded in the controlled substance count book, and the nurse on duty did not recall receiving them. The Director of Nursing confirmed the breach in protocol.
A resident with hypertension and C. diff was administered Hydralazine outside of prescribed blood pressure parameters and received Senna Plus despite having diarrhea and an active C. diff infection. The facility staff failed to follow physician orders, and the APRN and Assistant Director of Nursing were unaware of these deviations.
A facility failed to notify a resident's representative of significant changes in medical treatment, including new medications and the insertion of a foley catheter, for a resident with moderately impaired cognition. Despite the facility's policy requiring such notifications, there was no evidence that the representative was informed. Interviews confirmed the lack of communication, with the representative expressing dissatisfaction, particularly regarding the foley catheter insertion.
The facility failed to ensure nursing staff had the necessary competencies for wound VAC, PICC line, and IV medication administration. Several RNs and LPNs hired between 2021 and 2023 lacked documented training and competency assessments. The Staff Development Coordinator and DON could not provide evidence of completed training during a surveyor's investigation.
The facility was found to have multiple food safety and hygiene deficiencies, including improper cold holding temperatures for meals, failure of staff to wear required beard restraints, and improper storage of staff lunches with resident desserts. These issues were acknowledged by the Food Service Director during the survey.
The facility did not conduct a thorough facility-wide assessment to determine necessary resources for resident care during routine and emergency operations. The assessment lacked details on resident care needs, staff competencies, physical environment, and cultural considerations. It also failed to document resources like equipment, services, personnel, and third-party agreements. The Administrator acknowledged these deficiencies.
The facility failed to follow physician's orders for wound care and monitoring, resulting in deficiencies for several residents. A resident with multiple diagnoses did not receive required body audits and wound care treatments, while another with mild cognitive impairment had unaddressed edema. Additionally, a resident with severe cognitive impairment had a skin tear without proper documentation or provider notification. These issues highlight lapses in care and monitoring by the facility staff.
The facility failed to follow physician's orders for two residents. One resident, with diagnoses including failure to thrive and malnutrition, had orders to offload heels while in bed, but observations showed this was not done. Another resident, with diabetes, had orders for blood sugar checks with specific reporting parameters, but elevated levels were not reported to the provider. The DNS confirmed these failures, with no explanations provided.
Two residents in an LTC facility did not receive proper pressure ulcer care. One resident with severe cognitive impairment was not consistently using a Heelz-up device as ordered, and records falsely indicated compliance. Another resident's wound care deviated from the physician's order, using an incorrect dressing. Staff interviews confirmed these discrepancies, and the DON could not explain the failures.
A facility failed to properly manage a resident's PICC line and IV antibiotic administration. The resident, with multiple health issues, had a PICC line dressing saturated with dried blood, which was not changed despite acknowledgment by an LPN. Additionally, an RN did not follow IV priming protocol, resulting in medication spillage and improper handling of IV tubing. The Director of Nursing expected adherence to protocols, which was not observed.
The facility failed to maintain proper infection control during wound care for two residents. An LPN and SDC did not adhere to contact precautions, failing to perform hand hygiene and clean equipment. In another case, an RN exited a resident's room wearing a soiled gown and used a gloved finger to pack a wound dressing. The DNS confirmed these lapses, indicating a deficiency in the infection prevention and control program.
A facility failed to conduct weekly skin audits for a resident as per physician's orders, despite signing off on them as completed. The resident, with diagnoses including tinea cruris and type 2 diabetes, was hospitalized for wounds and a change in mental status, indicating neglect in wound care. The DON acknowledged the missed audits, which contributed to the deficiency.
Failure to Address Severe Weight Loss and Poor Intake
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for a resident admitted in November 2025 with diagnoses including kidney infection with obstruction and a recent hospitalization for DVT. The resident was identified as nutritionally at risk due to a mechanically altered diet, dysphagia, and infection, and the care plan included monitoring weights and consulting RD as needed. The resident's weights declined from 214.2 lbs. on readmission to 194.8 lbs. over a two-week period, representing a 9.06% loss of 19.4 lbs., which was documented as severe weight loss. The resident's intake records showed multiple meals with no intake documented or only 1-25% consumed between 12/15 and 12/18/2025. The facility policy stated that residents who tolerate less than 50% of a meal are to be offered a nutritional supplement and that significant weight loss should prompt notification of the physician, RD, DNS, and resident representative, but the record did not show that a supplement was offered when the resident ate less than 50% or that the RD or physician were notified of the weight loss. During interviews, the DNS stated nursing assistants should document meal intake and notify the nurse if intake is less than 50%, and the RD stated she was unaware of the resident's weight loss and poor intake until the surveyor brought it to attention.
Failure to Follow Bowel Protocol for Residents With Constipation
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents’ choices related to the bowel protocol for 8 of 8 residents reviewed who required such services. The facility policy stated that bowel management was intended to promote regular, voluntary, controlled bowel evacuation of normal consistency, and the protocol required prune juice on day 4 or after 72 hours without a bowel movement, Milk of Magnesia if there was still no bowel movement, Dulcolax suppository later that day, and a fleet enema on day 5 if no bowel movement occurred. Record review showed that each of the 8 residents had documented periods without a bowel movement lasting from 5 days to 37 days, including residents with diagnoses such as dementia, constipation, and need for assistance with personal care. For Resident #2, #9, #12, #32, #66, #73, #95, and #99, the MARs showed that the ordered bowel protocol interventions were not given when the residents met the criteria for treatment. In multiple instances, prune juice, MOM, Dulcolax suppository, and fleet enema were not administered on the required days despite the absence of a documented bowel movement. During interview on 12/19/2025, the DON acknowledged that the bowel protocol was not followed for the residents listed above. The DON was unable to provide evidence that the facility provided care in accordance with professional standards of practice relative to initiating the bowel protocol.
Failure to Include Trauma-Informed Care in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma received trauma-informed and culturally competent care in accordance with professional standards of practice. Resident ID #11 was readmitted to the facility in October 2024 with diagnoses including major depressive disorder severe with psychotic features. A Trauma Informed Care screen dated 10/8/2024 indicated the resident had experienced natural disasters, physical assault, verbal assault, financial struggle, and the loss of family members, and documented that the resident was still bothered by these events. Review of the comprehensive care plan showed that it did not include trauma-informed care or interventions to eliminate or mitigate triggers that may cause re-traumatization. During interviews on 12/18/2025 and 12/19/2025, the Social Worker acknowledged that the initial screen documented trauma but that it was not reflected in the care plan. On 12/19/2025, the DON was unable to provide evidence that a trauma-informed care plan was in place for the resident.
Failure to Act on Pharmacist Medication Review Irregularity
Penalty
Summary
The facility failed to ensure that irregularities identified by the Clinical Consultant Pharmacist during an admission/readmission medication regimen review were acted upon for one resident receiving antibiotics. The resident was readmitted in April 2025 with diagnoses including peripheral vascular disease and osteomyelitis of the right ankle and foot, and had a physician order dated 8/22/2025 for doxycycline hyclate 100 mg twice daily. The pharmacist’s medication regimen review dated 8/25/2025 noted that the continuity of care form listed doxycycline as a once-daily medication, while the facility entered it as twice daily, and the order needed clarification with the provider. Review of the record did not show evidence that the admission/readmission review with this irregularity was reviewed and acted upon by the resident’s provider. During interview, the DON was unable to provide evidence that the pharmacy consultation reports were reviewed by the provider and acted upon as required by facility policy.
Unnecessary Antibiotic Dosing Discrepancy
Penalty
Summary
The facility failed to ensure that Resident ID #6’s drug regimen was free from unnecessary drugs when the resident received doxycycline hyclate in a manner that did not match the discharge summary. The resident was readmitted in April 2025 with diagnoses including peripheral vascular disease and osteomyelitis of the right ankle and foot. A discharge summary from an acute care hospital dated 8/22/2025 ordered doxycycline hyclate 100 mg once daily for 6 days, for a total of 6 doses. The facility entered a physician’s order dated 8/22/2025 for doxycycline hyclate 100 mg twice daily for a total of 12 doses, and the August 2025 MAR showed the resident received 13 doses rather than the 6 doses listed on the discharge summary. A pharmacist’s medication regimen review dated 8/25/2025 noted that the discharge summary listed doxycycline as once daily, while the facility entered it as twice daily and needed clarification with the provider. The record did not show that the provider ordered the twice-daily regimen or that the order was clarified after the pharmacy identified the irregularity. During interview, the DON acknowledged the resident received 13 doses, which was 7 more doses than the discharge summary indicated.
Significant Medication Errors Not Prevented
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors for three residents reviewed. Resident ID #33, who was readmitted with diagnoses including sepsis and dementia, had a physician order for Cephalexin 500 mg every 6 hours for 5 days for cellulitis of the arm, but the December 2025 MAR showed that only 17 of the ordered 20 doses were administered. During interview, the DNS and Regional Infection Preventionist acknowledged the resident did not receive the ordered antibiotic doses, and the physician was not notified until after the surveyor brought the issue to the facility’s attention. Resident ID #46, admitted with diagnoses including dementia and schizophrenia, had an order for Eliquis 2.5 mg twice daily but did not receive doses on 11/25, 11/26, 12/6, and 12/17/2025 due to refusal, with no evidence that the physician was informed of the refusals. Resident ID #84, admitted with diagnoses including heart failure and atrial fibrillation, had multiple Warfarin orders and lab-based dosing reviews, but the MAR showed missed doses on 10/8, 11/10, and 12/8/2025. The DNS acknowledged that Resident ID #84 was not administered Warfarin as ordered on those dates, and the DNS was unable to provide evidence that Residents #33, #46, and #84 were kept free from significant medication errors.
Delayed Review and Reporting of PT/INR Results
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of laboratory results for 1 of 1 resident reviewed who was receiving Coumadin for anticoagulation therapy. The resident was admitted in March 2025 with a diagnosis including new onset unspecified atrial fibrillation and had a care plan focus area dated 3/19/2025 that identified anticoagulation therapy with interventions to monitor PT and INR bloodwork. Record review showed PT/INR bloodwork was drawn on 10/8/2025 at 6:20 AM and the lab document view history showed the results were not initially reviewed until 10/9/2025 at 11:40 AM. Another PT/INR bloodwork draw on 11/10/2025 at 6:12 AM was not initially reviewed until 11/11/2025 at 4:35 PM. Staff interviews revealed the PT/INR usually results between 2:00 PM and 3:00 PM the same day it is drawn, that the results are reviewed to ensure they are reported to the provider and the resident receives Coumadin that evening, and that the DON and the resident's physician expected the PT/INR to be reviewed the same day and reported immediately.
Incomplete and inaccurate documentation of ordered catheter care and protective devices
Penalty
Summary
The facility failed to ensure that resident records were complete and accurately documented for three residents related to ordered care and equipment use. Resident #9 had an indwelling foley catheter and a physician order to change the drainage bag to a leg bag every morning, but surveyor observations on multiple dates did not show the bag changed to a leg bag as ordered, even though the December 2025 TAR documented it as applied. During interview, an LPN acknowledged the foley drainage bag was not changed as ordered and that it was documented as applied when it was not. Resident #88 had a physician order to wear bilateral off-loading foot booties every night and remove them in the morning, and Resident #111 had orders for Geri-sleeves to the arms for all transfers and a right knee sleeve every morning and removal at bedtime. Surveyor observations on multiple dates did not reveal the booties, Geri-sleeves, or right knee sleeve in place as ordered, yet the TAR documented them as provided or applied. The resident with intact cognition stated the booties were not being applied at night, and an LPN acknowledged the booties, Geri-sleeves, and right knee sleeve were not applied as ordered but were documented as applied. The DON was unable to explain why the residents' records were incomplete and inaccurate.
Failure to Monitor Antibiotic Use and Complete Antibiotic Time Outs
Penalty
Summary
The facility failed to establish an Infection Prevention and Control Program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use for 2 of 3 residents reviewed for antibiotic use, Resident IDs #6 and #33. The facility’s undated Antibiotic Stewardship Program policy stated that antibiotic use should follow the five D’s: right diagnosis, right medication, right dose, right duration, and right de-escalation. CDC guidance cited in the report also called for antibiotic time outs 2 to 3 days after antibiotics are started to review whether the resident has a bacterial infection, whether the antibiotic is appropriate, and whether the spectrum or duration should be changed. Resident ID #6 was readmitted with peripheral vascular disease and osteomyelitis of the right ankle and foot. A hospital discharge form ordered doxycycline 100 mg once daily for 6 days, but the facility entered a physician order for doxycycline 100 mg twice daily for 12 doses and the MAR showed 13 doses were given. A pharmacist review noted the discrepancy between the discharge summary and the facility order and recommended clarification, but the antibiotic timeout completed later did not identify the mismatch or reflect the five D’s. Resident ID #33 was readmitted with sepsis and dementia. The physician ordered cephalexin 500 mg every 6 hours for 5 days for cellulitis of the arm, but the MAR showed 17 doses were administered instead of the 20 ordered. The antibiotic timeout for this resident also failed to show the five D’s, and the physician was not notified of the missed doses until after the surveyor brought the issue to the facility’s attention.
Failure to Follow Physician Orders and Monitor a Resident After Falls
Penalty
Summary
The facility failed to ensure services met professional standards of quality for a resident who fell and sustained a right femur fracture. The resident had a care plan identifying fall risk related to vertigo and impaired mobility, and after a physician note documented low blood pressure and directed orthostatic blood pressure checks, the record did not show that orthostatic blood pressures were obtained. Two days later, the resident fell again in the room between the bed and bathroom and was found to have a right femur fracture requiring hospital transfer and surgical repair. The record also showed that the resident was discharged with instructions to follow up with the surgeon in 10 to 14 days, but the follow-up appointment was not scheduled until the surveyor brought it to the facility’s attention. During interview, the LPN could not provide evidence that orthostatic blood pressures had been taken or that the follow-up appointment had been arranged. The scheduler stated she was responsible for appointments but had not been aware the resident needed the follow-up until staff informed her after the surveyor’s inquiry. The facility also failed to follow physician orders for two other residents. One resident had an order for bilateral off-loading booties to be on at bedtime and off in the morning, but the treatment record documented the booties as not on for multiple consecutive nights, and the resident was observed in bed without them. Another resident had an order to apply geri-sleeves and a pillow in front of the legs for all transfers with the stand aide device, but the resident was observed being transferred without the geri-sleeves in place. Staff acknowledged the orders were not followed, and the DNS and NP were unable to provide evidence that the ordered care was being carried out.
Foley Catheter Not Maintained Below Bladder Level
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a Foley catheter. The resident was admitted in March 2025 with flaccid neuropathic bladder, and the care plan dated 3/14/2025 included an intervention to maintain the Foley below bladder level. Lippincott Nursing Procedures states that the drainage bag should be kept below the level of the patient's bladder to prevent backflow of urine into the bladder and reduce the risk of CAUTI. During multiple surveyor observations, the resident was seated in a recliner with the Foley catheter tubing extending upward over the armrest and into the drainage bag, rather than being maintained below bladder level. This was observed on 12/16/2025 at 11:24 AM, 12/17/2025 at 10:54 AM and 3:41 PM, and 12/18/2025 at 2:55 PM. An LPN acknowledged during interview that the tubing was not below bladder level and stated that it should be. The DON also stated that staff would be expected to maintain the Foley catheter tubing below the resident's bladder level.
Failure to Provide Behavioral Health Services for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that a resident admitted with diagnoses including dementia with behavioral disturbances and schizophrenia received the necessary behavioral health care and services to attain or maintain the highest practicable well-being. The resident’s care plan addressed psychotropic medication use for schizophrenia and yelling out nonsensical dialogue, and a physician ordered Fluphenazine 5 mg every 8 hours as needed for severe agitation related to schizophrenia. The medication was administered once on 11/26/2025 for a behavior issue and documented as effective, then discontinued on 12/2/2025 after not being used within 14 days. Record review also failed to reveal evidence of a psychiatric consultation despite the resident’s schizophrenia diagnosis. Surveyor observations on multiple dates in December 2025 showed the resident repeatedly yelling out incoherent words in the common area, dining room, and hallway, with other residents appearing upset and yelling back. Staff observed that the resident’s yelling was frequent and described it as baseline. During interviews, staff stated the resident yells out all day, had no current PRN medication after the Fluphenazine was discontinued, and that the facility had not requested a psychiatric consult even though the resident needed one and needed PRN medication related to the behaviors.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential accidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular incidents or resident conditions described.
Failure to Administer Pain Medications per Physician Orders
Penalty
Summary
A deficiency was identified when a resident, recently readmitted with diagnoses including spinal fusion and orthopedic aftercare, did not receive prescribed pain management medications according to physician orders. The resident was ordered to receive a Buprenorphine patch on a specific date, but the medication was not available in the facility at the time, and a nurse signed off on the administration despite it not being given. This was confirmed through staff interviews and record reviews, which showed the patch was not applied as ordered. Additionally, the same resident was prescribed Dilaudid 4 mg by mouth every six hours as needed for pain, but records revealed that only 2 mg doses were administered on two occasions, contrary to the physician's order. Staff interviews confirmed that the lower dose was given, and the Medication Administration Record inaccurately reflected the administration of the full prescribed dose. The Director of Nursing acknowledged that the resident did not receive the medications as ordered.
Improper Handling of Controlled Medications
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with currently accepted professional principles, as evidenced by the mishandling of controlled medications. A review of the facility's policies revealed that only authorized, licensed nursing and pharmacy personnel should have access to controlled medications. However, a pharmacy shipping manifest showed that a Nursing Assistant (NA), Staff A, signed for the delivery of Buprenorphine patches, a controlled opioid medication, which is against the facility's policy. The controlled substance count book did not show evidence that the Buprenorphine patches had been received and added to the count, indicating a lapse in the proper documentation and handling of controlled substances. The incident involved a resident who was admitted to the facility with a chronic inguinal wound and pain to the left hip, for which a physician had ordered Buprenorphine patches. The patches were delivered to the facility, but the nurse on duty, Staff B, did not recall receiving them, and the NA who signed for them acknowledged that he should not have done so. The Director of Nursing Services confirmed that the NA improperly signed for the medication and that the controlled medication was not documented as received in the narcotic book, as required by the facility's policy.
Failure to Follow Physician Orders and Inappropriate Medication Administration
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice by not adhering to physician orders for a resident with hypertension and an active diagnosis of C. diff. The resident was admitted with diagnoses including hypertension and adult failure to thrive. A physician's order was in place for Hydralazine to be administered as needed for systolic blood pressure above 145. However, the medication was administered multiple times when the resident's blood pressure readings were below the specified parameters, indicating a failure to follow the physician's order. The Nurse Practitioner was unaware of this deviation, and the Assistant Director of Nursing could not provide evidence that the staff followed the order as written. Additionally, the resident was administered Senna Plus, a laxative, daily despite having diarrhea and a positive test result for C. diff. The administration of Senna Plus continued even after the resident's representative reported several loose stools, and a new physician's order was obtained to test for C. diff. The APRN stated that Senna Plus should not be administered during an active C. diff infection and was unaware that the resident was receiving it. The Assistant Director of Nursing confirmed that the medication was given despite the active diagnosis of C. diff and ongoing diarrhea, further highlighting the facility's failure to adhere to appropriate treatment protocols.
Failure to Notify Resident's Representative of Medical Changes
Penalty
Summary
The facility failed to notify the resident's representative of significant changes in the medical treatment of a resident with moderately impaired cognition, as indicated by a BIMS score of 9 out of 15. The resident, who was admitted with diagnoses including dementia and cognitive communication deficit, experienced several changes in medical treatment, including the initiation of new medications for high blood pressure and prostatitis, as well as the insertion of a foley catheter. Despite the facility's policy requiring notification of the resident's representative in such cases, there was no evidence that the representative was informed of these changes. Interviews with the resident's representative and facility staff confirmed the lack of communication regarding the resident's medical status changes. The representative expressed dissatisfaction with the facility's failure to communicate, particularly regarding the insertion of the foley catheter, which they would not have agreed to. Staff interviews revealed that the facility's policy mandates notifying the resident's representative of changes in medical status, especially for cognitively impaired residents, but this was not adhered to in this case.
Deficiency in Nursing Staff Competency and Training
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to provide safe and effective care to residents, as required by resident assessments and individual care plans. Specifically, the facility did not have evidence of completed competencies and skills sets for wound vacuum-assisted closure (Wound VAC) device management, peripherally inserted central catheter (PICC) line dressing changes, and intravenous (IV) medication administration for several licensed nurses. This deficiency was identified during a surveyor's review of records and interviews with staff members. The surveyor's investigation revealed that Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) hired between 2021 and 2023 had not completed the necessary training and competency assessments for these critical care procedures. During interviews, both the Staff Development Coordinator and the Director of Nursing Services were unable to provide evidence that the required education and competencies were completed before these nurses provided care. This lack of documentation and training was brought to the facility's attention by the surveyor, indicating a significant oversight in staff training and competency verification processes.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a survey. Firstly, the cold holding temperatures for turkey sandwiches and chef's salads were found to be significantly above the acceptable range, with temperatures recorded at 60 degrees F and 59 degrees F, respectively. This was observed during a lunch meal service on the North unit, and the Food Service Director acknowledged the discrepancy in temperature control. Additionally, the facility did not comply with the requirement for food employees to wear hair and beard restraints. A Dietary Aide, identified as Staff I, was observed on multiple occasions without a beard restraint while handling food and serving beverages. Furthermore, the facility improperly stored staff lunches in the same refrigerator as resident desserts, which is against the Rhode Island Food Code that mandates separate storage to prevent contamination. The Food Service Director confirmed the improper storage practice during an interview.
Facility Fails to Document Comprehensive Resource Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, dated [DATE], was found lacking in several critical components. It did not adequately address the care required by the resident population, considering their diseases, conditions, physical and cognitive disabilities, and overall acuity. Additionally, the assessment failed to identify the staff competencies needed to provide the required level and types of care for the residents. Furthermore, the assessment did not include essential details about the physical environment, equipment, services, and other physical plant considerations necessary for resident care. It also overlooked any ethnic, cultural, or religious factors that might affect the care provided, including activities and food and nutrition services. The document lacked evidence of the facility's resources, such as medical and non-medical equipment, services like physical therapy and pharmacy, personnel details, and agreements with third parties for services or equipment during normal and emergency operations. During an interview, the Administrator acknowledged these deficiencies in the facility assessment.
Deficiencies in Wound Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician's orders for several residents, leading to deficiencies in wound care and monitoring. Resident ID #273, who was readmitted with multiple diagnoses including an abscess and cellulitis, did not receive the required admission and weekly body audits as ordered. Additionally, the wound care treatments for this resident's right foot and heel were not completed as per the physician's orders, resulting in a lack of wound dressing changes for several days. Staff C admitted to signing off on these tasks without completing them, and was unaware of the resident's wound conditions due to not performing any assessments or treatments. Another deficiency was identified with Resident ID #64, who was admitted with hypertension and exhibited mild cognitive impairment. The resident was observed with mild edema in the lower legs and ankles over several days, yet there was no documentation or interventions recorded in the resident's file. Staff D was unaware of the edema and had not notified the resident's provider, leading to a delay in obtaining necessary physician's orders to address the condition. Resident ID #90, with severe cognitive impairment and neuropathy, was found with a bandage on the left shin without any documentation or orders explaining its presence. The bandage covered a scab and a skin tear, which appeared wet and soggy. Staff D acknowledged the lack of documentation and provider notification regarding the open area. The facility only obtained treatment orders for the skin tear after the surveyor brought it to their attention, indicating a failure to monitor and address the resident's skin integrity as per the care plan.
Failure to Follow Physician's Orders for Heel Offloading and Glucose Monitoring
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician's orders for two residents. Resident ID #73, who was readmitted with diagnoses including adult failure to thrive and malnutrition, had a physician's order to offload bilateral heels while in bed. However, surveyor observations over several days revealed that the resident's heels were not offloaded and were resting directly on the mattress. Interviews with the registered nurse and the Director of Nursing Services (DNS) confirmed the failure to follow the physician's order, with no explanation provided for the oversight. Additionally, Resident ID #85, admitted with a diagnosis of diabetes, had a physician's order for blood sugar checks twice a day with instructions to call the provider if levels were below 50 mg/dl or above 250 mg/dl. The September 2024 Treatment Administration Record showed multiple instances of blood sugar levels exceeding 250 mg/dl, yet there was no evidence that these were reported to the provider as required. The DNS acknowledged that the elevated blood sugar levels were not reported to the physician, despite expectations that staff would adhere to the physician's order.
Failure to Follow Pressure Ulcer Care Protocols
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for two residents, leading to deficiencies in treatment and prevention of pressure ulcers. Resident ID #35, who has severe cognitive impairment and was readmitted with an unstageable pressure ulcer on the right heel, was observed multiple times with their heels resting directly on the mattress, despite a physician's order to use a Heelz-up device to offload pressure. The treatment administration records inaccurately indicated that the device was used, and there was no evidence of resident refusal. Interviews with staff confirmed the non-compliance with the physician's order, and the Director of Nursing Services could not explain the oversight. Resident ID #103, admitted with a right femur fracture and muscle wasting, had a physician's order for specific wound care involving Vashe, medi-honey mixed with collagen powder, and a foam bordered dressing. However, during an observation, the registered nurse deviated from the prescribed treatment by using Puracol Plus AG with silver instead of the ordered medi-honey and collagen powder mixture. The nurse acknowledged the deviation, and the Director of Nursing Services was unable to provide an explanation for not following the physician's order.
Deficiency in PICC Line Management and IV Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding the management of a peripherally inserted central catheter (PICC) for a resident receiving intravenous (IV) antibiotic treatment. The resident, who was readmitted with conditions including an abscess, cellulitis, an ulcer, and diabetes mellitus, had physician orders for regular assessment of the PICC site and measurement of the external catheter. However, the facility's records showed that these measurements were signed off as completed without documentation. During an observation, the resident's PICC line dressing was found to be saturated with dried blood, and the dressing was not adhering properly to the skin. Despite acknowledgment from a Licensed Practical Nurse (LPN) that the dressing needed changing, there was no evidence that the dressing was changed or that the status of the PICC was documented. Additionally, during a medication administration task, a Registered Nurse (RN) failed to follow the facility's policy for priming the IV tubing, resulting in medication spilling onto the cart. The RN also placed uncapped IV tubing on the resident's bed, which is against protocol. The PICC line dressing was observed to have light red drainage, indicating a need for a dressing change, which was not documented as completed. The Director of Nursing Services expressed that it was expected for the IV to be primed per policy and for the PICC line dressing to be changed when necessary, but these expectations were not met as per the observations and record reviews.
Infection Control Lapses in Wound Care Procedures
Penalty
Summary
The facility failed to maintain proper contact precautions for a resident with MRSA in the nares and VRE in a wound. During a surveyor observation, a Licensed Practical Nurse (LPN) and the Staff Development Coordinator (SDC) were observed conducting wound care without adhering to infection control protocols. The LPN did not remove gloves or perform hand hygiene after handling personal items, and the SDC failed to clean scissors and surfaces before and after the procedure. The SDC also handled wound vac tubing without gloves and did not clean the equipment or surfaces before exiting the resident's room. In another incident, a Registered Nurse (RN) was observed performing wound care on a resident with a displaced fracture of the femur. The RN exited the resident's room wearing a soiled gown to retrieve additional supplies, failing to perform hand hygiene. Upon returning, the RN continued the procedure with the same gown and used a gloved finger to pack the wound dressing instead of a sterile implement like a q-tip. The RN acknowledged these lapses in protocol during a surveyor interview. The Director of Nursing Services (DNS) confirmed that the staff did not follow expected infection control practices. The DNS stated that the LPN and SDC should have performed hand hygiene and cleaned equipment and surfaces, while the RN should have used a q-tip for wound packing and removed the gown before leaving the room. These deficiencies highlight lapses in maintaining an effective infection prevention and control program, particularly in wound care procedures.
Failure to Conduct Weekly Skin Audits
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding skin assessments. A review of the facility's policy on skin protocol indicated that weekly skin observations were required for every resident, with documentation maintained in the residents' medical records. However, for one resident, there were seven weeks of missed skin audits, despite a physician's order for weekly body audits every Friday. These audits were signed off as completed in the Treatment Administration Record, but there was no evidence of the audits being conducted on the specified dates. The resident in question was readmitted to the facility with diagnoses including tinea cruris and type 2 diabetes. A community-reported complaint alleged that the resident was hospitalized for wounds and a change in mental status, suggesting neglect due to improper wound care. The resident was later seen by a wound physician for worsening wounds, resulting in new treatment orders. The Director of Nursing Services acknowledged during an interview that the weekly skin audits were not completed as ordered, contributing to the deficiency in care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 784 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Woonsocket
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Antoine Residence | 0.3 mi | ★★★★★ | 4 | 0 |
| Cedar Haven Operations Holding Llc Valley View Hea | 1.5 mi | ★★★★★ | 0 | 0 |
| Adviniacare Oakland Grove Llc | 2.3 mi | ★★★★★ | 12 | 0 |
| Woonsocket Health Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Holiday Retirement Home Inc | 3.8 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Friendly Home.
100% money-back within 48 hours.
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.