For five consecutive nights, nurses failed to apply protective booties to a resident's feet as ordered by their doctor. The resident told inspectors that staff didn't put the booties on at bedtime the night before the inspection on December 18.
When inspectors observed the resident in bed at 8:58 AM on December 19, the booties were missing. The licensed practical nurse on duty acknowledged the resident didn't have them on.
The resident had been admitted in January 2025 needing assistance with personal care but maintained intact cognition, scoring 14 out of 15 on a mental status assessment. Their care plan specifically called for bilateral off-loading foot booties due to impaired skin integrity.
The physician's December 15 order was clear: booties off in mornings, on at bedtime. But treatment records showed the morning shift nurse documented them as "no" or "off" every single day from December 15 through December 19, indicating they were never applied at bedtime as ordered.
A second resident faced similar neglect during transfers. Staff were ordered to apply protective sleeves to the resident's arms and place a pillow in front of their legs whenever using a stand-aid transfer device.
On December 17 at 11:11 AM, inspectors watched a nursing assistant transfer the resident using the device without the required protective sleeves. The assistant immediately acknowledged the sleeves weren't on during the transfer.
That resident had been admitted in February with atrial fibrillation and was identified as at risk for skin breakdown. Their care plan from October specifically included applying geri-sleeves as ordered to prevent injury.
The physician's June 20 order required the sleeves and pillow positioning for all transfers with the stand-aid device. But staff ignored the safety protocol.
When inspectors interviewed the Director of Nursing Services on December 18, she couldn't provide evidence that either resident received services meeting professional standards. A day later, she still couldn't show that staff were following the physician's orders for the second resident.
The facility's Nurse Practitioner told inspectors she expected staff to follow physician orders. The first resident's physician said he would have expected the protective measures to be implemented within 24 hours of ordering them.
Both violations represented failures to follow basic nursing standards. According to nursing fundamentals cited in the inspection, physicians direct medical treatment and nurses are obligated to follow those orders unless they believe the orders would cause harm.
The Director of Nursing Services wasn't made aware of the first resident's situation until December 17, only after the surveyor brought it to the facility's attention.
Neither resident suffered documented injuries from the lapses in care, but both faced unnecessary risk. The protective booties were designed to prevent skin breakdown on vulnerable feet. The geri-sleeves and pillow positioning were meant to prevent injury during transfers for a resident already at risk for skin problems.
The inspection found that some residents at The Friendly Home weren't receiving the basic protective care their doctors ordered. Staff acknowledged their failures but continued the patterns of neglect even as inspectors documented the violations.
For residents depending on nursing staff to follow medical orders that protect their health and safety, the repeated failures represented a breakdown in fundamental care standards. The facility's inability to ensure compliance with physician orders left vulnerable residents exposed to preventable harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Friendly Home from 2025-12-19 including all violations, facility responses, and corrective action plans.