Resident 88, who has intact cognition according to mental status testing, went without required protective foot booties for five consecutive nights despite a physician's order requiring them at bedtime. The resident's care plan specifically called for "bilateral off-loading foot booties as ordered" due to impaired skin integrity.
The physician had ordered the booties off in mornings and on at bedtime starting December 15. But nursing records show morning shift nurses documented the booties as "no" or "off" on December 15, 16, 17, 18, and 19 — indicating staff failed to apply them the previous nights as ordered.
When an inspector visited the resident's room at 8:58 AM on December 19, the resident was in bed without booties. The resident confirmed staff had not applied the protective equipment at bedtime the night before.
LPN Staff C acknowledged the resident didn't have the booties on when questioned immediately after the observation.
A separate incident involved Resident 111, who has atrial fibrillation and was admitted in February. The resident's care plan identified a risk for skin breakdown and required applying protective arm sleeves during transfers with a mechanical lift device.
A physician had ordered geri-sleeves for the resident's arms and a pillow for leg protection during all transfers using the stand aide device. The order dated back to June 20.
But on December 17 at 11:11 AM, an inspector watched Nursing Assistant Staff D transfer the resident using the stand aide without the required protective sleeves. Staff D immediately acknowledged the resident wasn't wearing the geri-sleeves during the transfer, despite the physician's order.
The facility's Director of Nursing Services couldn't provide evidence that staff were following either physician's order when questioned by inspectors on December 19.
She also couldn't demonstrate that Resident 32 received services meeting professional standards of quality, though details of that case weren't fully documented in available records. The DNS only became aware of issues with Resident 32 on December 17 after the surveyor brought them to the facility's attention.
A physician interviewed about Resident 32 said he would expect orthostatic blood pressure monitoring completed within 24 hours and follow-up appointments scheduled, though the inspection report doesn't detail what monitoring or appointments were missed.
The facility's Nurse Practitioner told inspectors she would expect staff to follow physician orders.
Federal nursing regulations require facilities to ensure residents receive treatment and care in accordance with professional standards of practice. The regulations specifically state that nurses are obligated to follow physician orders unless they believe the orders are in error or would harm residents.
The violations affected multiple residents and represented a pattern of staff failing to implement basic protective measures ordered by physicians. In Resident 88's case, the failure to apply protective booties continued for five straight nights despite clear documentation requirements.
For Resident 111, staff ignored safety protocols during transfers that could prevent skin tears and injuries during mechanical lift operations.
The inspection classified the violations as causing minimal harm or potential for actual harm, affecting some residents. But the repeated nature of the failures — spanning days for one resident and involving multiple staff members — suggests systemic problems with following medical orders.
Resident 88 has been living at the facility since January with diagnoses requiring assistance with personal care. Despite scoring 14 out of 15 on cognitive testing, indicating intact mental function, the resident couldn't ensure staff followed the physician's protective equipment orders.
The nursing assistant who transferred Resident 111 without protective sleeves acknowledged the violation immediately when questioned, suggesting staff knew the requirements but chose not to follow them.
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.