The Friendly Home

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 12/11/2025 to 12/19/2025, it was determined that for one (Resident #61) of five residents reviewed, the facility did not ensure that PRN (as needed) orders for anti-psychotic drugs (medications used to treat symptoms of psychosis) were limited to 14 days. Specifically, there were several instances in which Resident #61 had as needed (PRN) Haldol (an antipsychotic medication) orders that exceeded the 14 day timeframe. Additionally, over several months, Pharmacist #1 identified through monthly Medication Regimen Reviews the Haldol orders and recommended they be reordered every 14 days. This is evidenced by the following: Resident #61 had diagnoses including dementia, depression, and anxiety. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a recertification survey from 12/11/2025 to 12/19/2025, for two (2) (Resident #33 and #140) of three (3) residents reviewed for respiratory care, and two (2) (Resident #6 and #88) of five (5) residents reviewed for drugs and medications, the facility did not provide services to meet professional standards of quality. Specifically, Resident #6 had physician's orders for blood pressure to be obtained prior to receiving blood pressure medication, and the facility could not provide documentation the blood pressure was consistently obtained prior to the administration of the medication per the medical order. Resident #33 and Resident #140 had reportable instances of high blood glucose, and the facility could not provide documentation a medical provider was notified per the medical order. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during recertification and complaint (#2619460) surveys from 12/11/2025 to 12/19/2025, for three (3) (Resident's #85, #125, and #126) of ten (10) residents reviewed, the facility did not ensure the resident's environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents. Specifically, Resident #85 was observed over several days to have unopened wine bottles unsecured at their bedside, Resident #85 was not care planned for personal alcohol possession or consumption and there were other residents with wandering tendencies residing on that unit. [...]

Inspectors wroteBased on observations and interviews, for one (1) of one (1) resident reviewed (Resident #138), the facility failed to ensure the resident was treated with respect and dignity and cared for in a manner and environment that promotes the maintenance or enhancement of the resident's quality of life. Specifically, staff entered the resident's room without knocking or announcing their presence, failed to communicate with the resident during care interactions, and moved the resident's personal items without discussing the action with the resident.

Inspectors wroteBased on observations, interviews, and record review, review conducted during recertification and complaint (#2691821) surveys from 12/11/2025 to 12/19/2025, the facility failed to ensure residents were free of significant medication errors for three (3) of six (6) residents reviewed (Residents #33, #88, #154). Specifically, Resident #33 received insulin outside of administration parameters included in the medical order. Resident #88 received insulin outside of administration parameters included in the medical order and received insulin without documented evidence a blood glucose measurement was obtained prior to administration. Resident #154 did not receive medications and treatments in accordance with physician orders for multiple days after returning to the facility following a hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medications were stored securely and accessible only to authorized personnel, in accordance with professional standards of practice and State and Federal regulations, for two (2) of four (4) residential units reviewed ([NAME] Place and [NAME] Place). Specifically, multiple loose pills (unsecured medications that were not contained in labeled packaging) were observed in medication carts, and a medication cart was observed unlocked and unattended.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey from 12/11/2025 through 12/19/2025, the facility did not ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (3) (Residents #11, #69, and #184) of six (6) residents reviewed. Specifically, Resident #11 had catheter care performed, the new drainage bag was observed on the floor uncovered and a nurse stepped on it. [...]

Inspectors wroteBased on record review and interview conducted during the Recertification Survey, it was determined that for four (Employees #1, #3, #4, and #5) of five newly hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, the results of a nurse aide registry abuse screening were not documented for newly hired employees prior to starting work.

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and an antibiotic stewardship program (processes to ensure that individuals are receiving appropriate antibiotics, at the correct dose, and for the proper length of time) that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility could not provide evidence of on-going surveillance and tracking of infections since June 2023 and there was no evidence that the facility had been maintaining an antibiotic stewardship program. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #53) of six residents reviewed for Activities of Daily Living, the facility did not ensure that a resident with limited range of motion received the appropriate treatment and services to prevent further decline. Specifically, Resident #53 had contractures (deformities that result when muscles, joints, tendons, or other tissues tighten or shorten) to both hands and was not provided the hand devices (hand rolls) per their plan of care to prevent a decline. Additionally, the facility could not provide documented evidence that Resident #53 received range of motion per their plan of care. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #53) of one resident reviewed for tube feedings (nutrition administered via a tube inserted directly into the stomach via the abdomen due to the residents' inability to consume food and drink by mouth), the facility did not provide appropriate treatment and services to prevent potential complications for a resident who receives enteral feedings (tube feedings), as outlined by the resident's person-centered comprehensive care plan and physician orders. Specifically, the facility was unable to provide documented evidence that the resident had received the correct tube feeding and water intakes as ordered by the physician to ensure the necessary nutrition and prevent complications. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of five medication carts reviewed for medication storage, the facility did not ensure that all drugs and biological were properly stored in accordance with State and Federal Laws. Specifically, two expired medications were stored in medication cart #1on [NAME] Place resident care unit and a medication cart on [NAME] Place had multiple loose unlabeled pills. In addition, one of the medication drawers in the cart on [NAME] Place contained a large amount of debris at the bottom of the drawer. This is evidenced by the following: [...]

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey, the facility did not ensure that the individual designated as the facility's current Infection Preventionist (individual responsible for the facility's Infection Prevention and Control Program) had completed specialized training in infection prevention and control. Specifically, the facility's designated Infection Preventionist did not have documented evidence of completing specialized infection prevention and control training. This is evidenced by the following: The facility policy, Infection Control Program, dated 12/13/23, defined the Infection Preventionist as a person whose primary training was either in nursing, medical technology, microbiology, or epidemiology and who had acquired additional training in infection control. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey, it was determined that for one of one main kitchen the facility did not properly maintain essential equipment. Specifically, a high-temperature mechanical dish machine did not reach the required final rinse temperature to properly sanitize dishes.

Inspectors wroteBased on observations and interview conducted during the Recertification Survey completed on 3/2/22, it was determined that for four ([NAME], Porter, [NAME], and [NAME]) of six resident units and one of one main lobby, the facility did not ensure that the resident's environment remained free of accident hazards. Specifically, hot liquids were accessible to residents and a heating surface exceeding 125°F was not adequately protected from accidental contact.

Inspectors wroteBased on interviews and record review conducted during a Recertification and complaint investigation (#NY00270684) Survey, completed on 3/2/22, it was determined that for one (Resident #346) of three residents reviewed, the facility did not permit a resident to return to the facility following an acute transfer to the hospital. Specifically, the resident was transferred to the hospital and upon receiving a referral from the hospital for a readmission, the facility determined they could not meet the resident's needs without proper notification per the regulation. This is evidenced by the following: Resident # 346 was admitted to the facility on [DATE] and had diagnoses including leukocytosis (acute elevation of white blood cell count) and heart failure. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey, completed on 3/2/22, it was determined that for 2 Residents (#22 and #106) of 26 residents reviewed for care planning, the facility did not develop and implement a comprehensive person- centered care plan that included measurable objectives to meet the resident's medical, nursing, mental and psychological needs as identified in the comprehensive assessments. Specifically, Resident #22's Comprehensive Care Plan (CCP) did not include the resident's suprapubic (SP) urinary catheter or congestive heart failure with edema (excess fluid), and Resident #106 CCP did not include the use of a psychotropic (medications that affect mental function and behavior) medication. This was evidenced by: 1. Resident #22 had diagnoses that included Parkinson's disease, urinary retention, and heart failure. [...]

Inspectors wroteBased on interview and record review during a Recertification Survey, and complaint investigation (#NY00270684), completed on 3/2/22, it was determined that for two (Residents #146 and #346) of three residents reviewed, the facility did not provide evidence that a valid written notification of transfer or discharge was sent to the residents or resident representatives in a timely manner. Specifically, Resident #146 was not provided a notice of transfer or discharge following a hospital admission and Resident #346 was not provided a valid notice of discharge that included the reason for the discharge, complete and correct appeal information and did not supply evidence of a reason for inabilty to return as per the regulations. This is evidenced by the following: 1. [...]