Friendly Village Nursing And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure unlicensed staff would not administer medications to 1 resident (R27) for 5 residents reviewed for medication administration in a sample of 23 residents.Certified Nursing Assistant (CNA) D was observed by Surveyor applying a Lidocaine external patch 4% to R27's back.Findings include:The facility policy titled Administering Medication, revised 01/22/2024, states, Only licensed staff.may administer or record the administration of medications.certified medication technicians may administer specific medications under the direction of a licensed nurse if competency has been determined.R27 was admitted to the facility on [DATE] and has diagnoses of cerebral palsy and back pain. R27 has a physician's order for Lidocaine external patch 4% - apply to lower back topically two times a day for pain. On in AM and off in the evening. On 04/21/2026 at 9:05 AM, Surveyor observed CNA D apply a Lidocaine external patch to R27's lower back after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure standard and transmission-based precautions are followed to prevent spread of infections for 2 residents (R27, R25) of 23 residents reviewed for infection control precautions in a sample of 23 residents. The facility failed to prevent possible transmission of infection/disease to R25 and R27 as follows: Staff did not wear personal protective equipment (PPE) during cares performed for R27 who is on enhanced barrier precautions (EBP). Staff did not perform hand hygiene before and after cares performed for R27. Staff used contaminated gloves during application of topical cream to buttock and applying a new dressing to suprapubic catheter site for R27. Urinary catheter drainage bag lying on floor at foot of R25's bed without a protective barrier between drainage bag and floor. Findings include:The facility policies, titled Enhanced Barrier Precautions, dated 03/26/2024, and Hand Hygiene, last revised 05/08/2024, state, Staff will perform…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not store resident foods brought in by visitors in a manner to prevent food-borne illness. The facility practice had the potential to affect 59 of 76 residents who reside on the main level of the facility on the 100, 200, 300 and 400 wings. The facility did not ensure the low temperature dishwasher chemical sanitizer maintained the correct concentration per manufacturer's guidelines. The facility practice had the potential to affect all 76 residents who are served foods from the facility's kitchen. Surveyor observed foods and beverages brought in for residents by visitors in 2 refrigerators/freezers in the nurses' station that were not labeled by resident or dated with received by and use by dates. Surveyor observed dish machine logs showing the low temperature dishwasher did not maintain appropriate chemical sanitizer minimal parts per million. This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure the mandatory staffing data that had been submitted from 7/1/24-9/30/24 was complete, accurate, and auditable. This has the potential to affect all 76 residents that reside in the facility. This is evidenced by: The facility policy titled Payroll Based Journal dated as revised on 2/26/22 in part read: Policy: Long-term facilities must electronically submit to CMS (Centers for Medicare and Medicaid Services) complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. Procedure: ~The facility must submit to CMS complete and accurate direct care staffing information, including: The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, other type of medical personnel as specified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide a notice of transfer to residents or resident representatives. This affected 4 of 4 sampled residents (R8, R9, R20, and R73). -A notice of transfer was not provided prior to a facility-initiated discharge for R8, R9, R20, and R73. -The facility did not inform the residents or their representatives, prior to a transfer, of appeal rights, including the name, address, and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. Findings include: The facility's policy, Policy & Procedure Admission, Readmission, Bed Hold, and Transfer/Discharge, read in part, Transfer/Discharge. Before the facility transfers or discharges a resident, the facility must- -Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) for 2 of 2 residents (R) reviewed for Preadmission Screening and Resident Review (PASARR) screen. (R18 and R48) -The MDS assessments are coded in error stating that a PASARR level 2 screen had not been completed when it was completed at the time of assessment for R18. -The MDS assessments are coded in error stating R48 had a serious mental illness when, in fact, the mental illness was a result of progressive dementia. Findings include: Example 1 R18 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, and PTSD. Record review identified R18 had a PASARR level 2 screen completed on 03/03/22. R18's comprehensive MDS assessment, dated 01/13/25, indicated for question A 1500 that No PASARR level 2 had been completed. Example 2 R48 was admitted to the facility on [DATE] with diagnoses that include dementia with severe agitation and delusional disorders. Surveyor was unable to find that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the resident (R) maintained acceptable parameters of nutritional status for 1 out of 3 residents reviewed for nutrition. R5 did not receive the assistance R5 required with eating. Weights were not obtained in over 60 days when R5 had been identified for high risk for altered nutrition. R5 had a recorded significant weight loss, and the facility did not reassess significant weight loss or her ability to feed herself. Findings include: The facility policy titled, Resident Height and Weight last revised 1/7/2025, documents, in part: All residents will be weighed upon admission and subsequently as the policy directs to provide a baseline and ongoing record for monitoring stability of weight as an indicator of nutritional status and medical condition over a period of time. Nursing department staff and Registered Dietitian (RD) will cooperate to prevent. Monitor, and provide intervention for undesirable weight variances for our residents .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on meal observations, interviews and record review, the facility failed to distribute food under sanitary conditions, improper glove use, and food handling without proper hand hygiene. This has the potential to affect all 78 residents who reside in the facility. This is evidenced by: The facility policy and procedure entitled: Sanitization and Cleaning Schedule, states in part . 2. All foodservice employees must use one of two acceptable sanitary procedures when handling foods: a. Hands are washed using appropriate procedure and food is handled with tongs, deli paper or other utensils. b. Disposable gloves are used and changed when soiled, torn, or switching tasks. 3. Bare hand contact with ready to eat food is not permitted by dietary staff preparing or serving the food. On 01/08/24 at 7:48 AM, Surveyor observed Dietary Aide (DA) G dishing food onto plates to all residents. During food service process, Surveyor observed DA G resting gloved hands onto steam table and lean up against steam table with scrub top. DA G held the pen and clipboard to write food temps half-way…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record reviews, the facility did not maintain an infection prevention and control program according to professional standards of practice when droplet precautions of appropriate Personal Protective Equipment (PPE) were not followed, and improper hand hygiene was performed during cares. This affected 4 of 4 residents (R49, R72, R16, R71) observed for infection control. This is evidenced by: The facility policy entitled: Isolation Precautions under the category Droplet Precautions, states in part .3. Prior to entering the isolation room, the following steps are required: a. Perform hand-hygiene and apply gloves, gown, and mask prior to entering room. The facility policy entitled: Hand Hygiene, states in part, staff are to wash hands with soap or water or use alcohol-based hand gel .Before applying and after removing gloves . before moving from a contaminated body site to a clean body site during resident care; example: after providing peri-care, before applying moisture barrier or other treatments . Example 1 On 01/09/24 at 9:27 AM, Surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure care plans were reviewed and revised based on changed needs and goals for antidepressant medications for 1 of 18 residents (R48) reviewed. This is evidenced by: R48 was admitted to the facility on [DATE]. R48's diagnoses include dementia with behaviors, anxiety disorder, and depression. R48's Minimum Data Set (MDS) dated [DATE] indicates Brief Interview for Mental Status (BIMS) of 10, which means R48 has a moderate cognitive impairment. R48's physician orders dated 01/25/23, includes in part, Citalopram 10mg by mouth once a day until 02/15/23, then give Citalopram 20mg once a day for severe depression. Surveyor reviewed R48's care plan with a target date of 01/09/24 where there is no mention of the antidepressant medication Citalopram which R48 is currently receiving. The care plan did include use of an antianxiety medication lorazepam which was confirmed by physician orders R48 was no longer receiving as of 01/11/23. On 01/11/23 at 8:31 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene following urinary incontinence for 1 of 4 residents reviewed (R16) for toileting and hygiene assistance. This is evidenced by: The National Association for Incontinence ([NAME]) states in part, .Urinary incontinence leaves the aging population at risk for impaired skin integrity. Exposure to urine and feces is one of the most common causes of skin breakdown . The [NAME] goes on to state that urinary incontinence makes the skin more susceptible to maceration, incontinent dermatitis, bacterial infections, fungal infections, and exposure to caustic agents, such as ammonia, a prime caustic agent in urine. [NAME] goes on to state, . Timely cleansing of the perineal area by using gentle, but effective, cleansers is essential to maintaining skin integrity, controlling odor, and providing comfort and improved self-esteem . R16 has medical diagnoses that include, but are not limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that a resident with a pressure injury (PI) received correct treatment and services, consistent with professional standards of practice, to promote healing for 1 of 1 resident (R) reviewed for PIs. (R4) Findings include: R4 was admitted to the facility on [DATE] with diagnoses, in part of pressure ulcer of sacral region, stage 4, diabetes, muscle wasting and weakness, and abnormalities of gait and mobility. R4's care plan revised on 12/26/23 indicates that R4 is at risk for PIs and had a PI to right buttocks. Interventions include to administer treatment as ordered. According to R4's Minimum Data Set (MDS) assessment, dated 10/06/23, R4 is cognitively intact. R4 is dependent on staff for all mobility, transfers, and toileting and is unable to stand or walk. R4 uses a Foley catheter and was always incontinent of bowel. R4 was assessed at risk for developing PIs and had one stage 4 unhealed PI at the time of admission. On 01/09/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record reviews, the facility failed to provide pharmaceutical services related to the accurate administration of steroid inhaler to meet the needs for 1 of 1 resident reviewed (R20). This is evidenced by: Surveyor reviewed manufacturer's instructions for Symbicort on My Symbicort.com, which states, Symbicort may cause serious side effects, including . fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using Symbicort to help reduce your chance of getting thrush . On 01/09/24 at 3:09 PM, Surveyor observed Licensed Practical Nurse (LPN) N enter R20's room with eye medication and an inhaler. LPN N educated R20 to take a deep breath in and to exhale and then administered one puff of Symbicort Aerosol 160 MCG/4.5 with a spacer or aero-holding device. LPN N administered a second puff at 3:11 PM. LPN N did not educate or offer oral rinsing following this administration. On 1/10/24 at 1:27 PM, Surveyor interviewed Director of Nursing (DON) B regarding the expectation of staff with the administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. The facility did not report to local authorities when R2 pushed R1 to the ground. The facility reported incident (FRI) indicated R2 pushed R1 and caused her to fall to the floor. R1 experienced pain and required a transfer to the emergency room for evaluation. The facility did not report the incident to local authorities as outlined in the facility policy. This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled, Vulnerable Adult Abuse and Neglect Prevention which is most recently dated 10/03/22. The policy reads in part: Purpose: To provide residents a safe environment that is free from harm. Investigation: ~If it appears that maltreatment may involve a crime, immediately notify the police as directed . Reporting of Incidents: ~Call law enforcement officials if suspected concern is criminal in nature (theft, assault, unwanted touch,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.