British Home, the

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow therapeutic diet orders, failed to ensure nutritional supplements ordered by the Registered Dietician were provided during meals, and failed to monitor, assess, and document meal/nutritional intake of residents. This failure affected three residents (R1, R7, R28) in a sample of 20 residents reviewed for nutrition. These failures have the potential to affect 35 residents that receive oral intake at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure portion sizes were adequate, failed to ensure portion sizes were served according to the recipe, and failed to weigh food products to ensure correct serving sizes prior to serving in accordance with professional standards. These failures affect all 35 residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label/store food items in accordance with professional standards, failed to discard expired or undated food products, failed to clean non-food surfaces to prevent the build-up of grease, failed to repair walls of the kitchen to ensure the wall was able to be cleaned in accordance with professional standards, and failed to complete regular quality assurance monitoring of sanitization procedures in the kitchen. These failures affected all 35 residents that consume nutrition from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete an accurate facility assessment, failed to ensure all requirements of the facility assessment were reviewed and addressed, failed to ensure residents/their representatives were involved in the completion of the facility assessment, failed to identify any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services, failed to consider specific staffing needs for each resident unit and shift in the facility, and failed to identify utilized agency nursing contracts to provide agency nursing staffing services during normal operations. These failures has the potential to affect all 37 residents that reside within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate ventilation of steam released above the dish machine which caused water damage and degradation of the ceiling tiles above the dish machine/dishwashing area. These failures have the potential to affect all 35 residents that consume food from the kitchen.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to ensure that the correct date was documented on resident dry erase boards and failed to ensure call lights were within reach for six of 20 residents (R15, R25, R31, R33, R34, R43) in the sample reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This failure has the potential to affect all 21 residents residing on the second floor reviewed for labeling of medications and biologicals. On 5/13/2026 at 10:30 am, surveyor inspected the 2nd floor medication storage room with V22, LPN (Licensed Practical Nurse). In the inside door of the refrigerator, one multi-dose vial of Tuberculin 5T/0.1 ml (milliliters), stored in the original packaging box, was opened and not dated. V22 (LPN) affirmed there was no open date on the Tuberculin vial. V22 (LPN) stated generally Tuberculin is good for 45 days and then discarded. On 05/13/2026 at 1:59 pm, V2 Director of Nursing (DON) was asked about labeling of medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Advance Directives care plan was congruent with the POLST (Practitioner Order for Life-Sustaining Treatment) and/or Physician Orders for one of 20 residents (R15) in the sample reviewed for resident rights.

Inspectors wroteBased on interview and record review, the facility failed to refer one resident (R4) with a possible serious mental disorder for Screening and Resident Review to the appropriate state-designated authority for further assessment as required. This failure affected one resident (R4) reviewed for pre-admission screening in the sample list of 37 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to one of 20 dependent residents (R16) in the sample reviewed for quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that hospice orders/hospice care plan was accessible to staff, failed to identify resident change in condition, failed to notify the physician of change in condition timely, failed to document an accurate physical assessment and failed to obtain physician orders for two of 20 residents (R16, R28) in the sample reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a LALM (Low Air Loss Mattress) was turned on while in use, failed to identify a skin integrity impairment, failed to implement preventive interventions, failed to notify the physician/nurse practitioner of change in skin condition, failed to document a wound assessment for two days and administered dressings without physician orders, and failed to obtain treatment orders for two of 20 residents (R15, R25) in the sample reviewed for pressure ulcers. These failures resulted in R25's right heel wound identified by surveyor on 5/11/26. Findings Include: 1. R25's medical history is significant for colon cancer with liver metastasis, congestive heart failure, peripheral vascular disease, falls with compression fractures of the thoracic vertebrae (at level T5-T6), and atrial fibrillation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that an opened gallon of distilled water used for tube feeding flushes was labeled with an open date for one resident (R33). This failure affected one resident (R33) reviewed for tube feeding management in the total sample of 37 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure policy procedures include storage for respiratory devices when not in use and failed to contain respiratory equipment when not in use for two of 20 residents (R16, R23) in the sample reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order was written and in the electronic medical record physician orders for one (R29) resident of one resident reviewed for dialysis care.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain accurate records and document administration of controlled substances for one (R51) of one resident reviewed for pharmacy services in a sample of 21 residents residing on the second floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedure and failed to ensure a resident was free from significant medication errors. These failures affect one resident (R33) in a sample of 37 residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential equipment was maintained in safe operating condition when an IV pump identified as malfunctioning continued to be used for resident care. These failures affect one resident (R33) in a sample of 37 residents reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy in conducting background checks for 1 of 10 residents (R34) reviewed for admission screening, and nine of ten (V9, V15, V16, V17, V18, V19, V20, V21, and V23) employees prior to hire. This failure has the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food is prepared and served under the sanitary conditions, failed to ensure food items were labeled and dated per facility policy, and failed to ensure high-temperature dishwasher final rinsing cycles gauge temperature worked properly during final rinse. These failure applies to 37 residents who receive food prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess new skin condition on a resident with impaired mobility, and failed to notify licensed staff to evaluate skin for one (R24) of three residents in the sample of 30 reviewed for skin impairment. This failure resulted in R24 developing a new wound excoriation on right buttock area.

Inspectors wroteBased on interview and record review, the facility failed provide supervision to prevent a fall of a resident (R194) in the bedroom next to the nursing station, affecting one resident (R194) of 3 residents reviewed for falls. Findings Include: R194 is an [AGE] year-old female admitted to the facility on [DATE], with a medical diagnosis that includes but is not limited to dementia, cerebral infarction, right below-the-knee amputation, Covid-, 19, hypertension, left-sided weakness, and urinary tract infection. On the (MDS) Minimal data Set assessment of 2/23/2025, section C, the BIMS (Brief Interviewed Mental Status) score was 06/15, and indicates severe cognitive impairment. On MDS of 2/23/2025, GG section, R194 is dependent to move from Chair/bed-to-chair transfer. The ability to transfer to and from a bed to a chair (or wheelchair). Helper does ALL of the effort. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered; and failed to follow policy and manufacturer's guidelines in the administration of inhaler and insulin pen. There were 25 opportunities with three errors resulting in a 12% medication error rate. The errors involved three (R10, R25 and R141) of 16 residents in the sample of 30 reviewed for medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label a multi-dose medication with an open and a used by date. The facility also failed to lock the medication refrigerator in the medication room for the first floor, for one of one medication rooms reviewed for medication storage.

Inspectors wroteBased on interview and record review, the facility failed to transmit admission and discharge assessments within 14 days of completion for six of six residents (R6, R39, R40, R45, R52, R54) reviewed for resident assessments in a sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the urine collection bag was covered and that complete privacy is provided during wound care for three of four residents (R25, R217, R220) reviewed for resident's rights in a sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for storage of respiratory care supplies for one of four residents (R59) reviewed for respiratory care in a sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices during wound care for one of one resident (R25) reviewed for wound care in a sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to properly position a resident (R1) in bed to prevent the resident from falling out of bed onto the floor, failed to properly assess R1 after his fall incident and prior to moving the resident post fall, and failed to follow facility policy by leaving resident unattended during fall event. These failures resulted in the resident being sent out emergently to a local hospital in pain, and R1 was diagnosed with dislocation to his right hip which required surgical intervention. This failure affected one (R1) of three residents reviewed for accidents.