Brighton Bay Center for Rehabilitation and Healing

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure surgical wounds were assessed and measured for three residents (#2, #6, #7) out of three sampled residents.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to ensure a safe and homelike environment was provided in 13 resident rooms (#201, #203, #118, #114, #108, #107, #110, #112, #259, #253, #138, #137, and #146) of 74 resident rooms in the facility.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were accurate and updated to include current diagnoses for three residents (#29, #28, #77) out of 28 sampled residents.

Inspectors wrote4. On 3/26/25 at 9:49 a.m., an observation was made of Staff C, Registered Nurse (RN). Upon entering Resident #38's room, no hand hygiene was performed. Staff C, RN obtained Resident #38's blood pressure using reusable equipment for multiple resident use. Throughout the observation, no had hygiene was performed and the reusable equipment was not observed to be cleaned prior to or after use. Based on observations, record reviews, and interviews, the facility failed to 1. Implement an effective infection control program related to the use of Personal Protective Equipment (PPE) in one resident (#162) room of four transmission-based precaution rooms; 2. Failed to store or dispose an indwelling catheter bag when not used for one resident (#78) of six sampled residents who utilized catheters; and 3. [...]

Inspectors wroteDuring an interview on 3/25/2025 at 10:00 a.m. with the Director of Nursing (DON), the DON stated no PASRRs were submitted for a Level II review. Based on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for one resident (Resident #79) of ten residents sampled for PASARR.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-six medication administration opportunities were observed, and three errors were identified for three residents (#90, #27, and #38) out of four residents observed. These errors constituted a 8.33% medication error rate.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide food to accommodate preferences for two residents (#39 and #66) out of twenty-two residents sampled for food.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to assess and obtain wound care orders for one (#12) of two residents reviewed for wound care.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure laboratory testing was obtained per physician orders for one (#12) of two residents sampled.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure 1) expired supplements and medications were discarded from three of the six medication carts, and 2) medications were stored appropriately for three residents (#50, #10, and #52) out of 43 sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure an assessment for self-administration of medications was completed for two residents (#44 and #88) out of the 28 residents observed on the west hall of the first floor.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to do an ongoing re-evaluation of the need for a restraint for one resident (#43) out of one resident with a restraint.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to 1) develop a baseline care plan within 48 hours of admission; and 2) provide a written summary of the baseline care plan to the resident/resident representative for two residents (#367 and #214) out of 43 sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to develop and implement care plans for three residents (#69, #55, and #103) of forty-three sampled residents. It was determined care plans were not developed and implemented related to dental/oral status for Resident #69, diabetic diagnosis and care for Resident #55, and smoking/ smoking safety for Resident #103.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure 1) a discharge care plan was in place, 2) a discharge summary was completed, and 3) post care discharge plans were documented for two residents (#112 and #113) out of three residents sampled for discharge.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to 1) ensure one resident (#103) smoked in the designated smoking area and was adequately assessed for smoking out of three residents sampled for smoking.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure 1) respiratory care was provided consistent with professional standards of practice related to oxygen levels not set per physician orders for one resident (#72), and 2) respiratory equipment was stored appropriately for four residents (#72, #10, #62 and #73) out of five residents sampled during two of four days of survey.

Inspectors wroteBased on record reviews, and interviews the facility failed to ensure insulin administration was adequately and appropriately monitored for two residents (#74 and #55) out of 7 resident reviewed for unnecessary medications and insulin administration.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure behavioral/side effect monitoring was conducted for psychotropic medications for one resident (#74) out of five residents sampled for unnecessary medications administration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed with four errors identified for two residents (#51 and #17) of seven residents observed. These errors constituted a 14.29% medication error rate. Findings Include: 1. On 02/21/23 at 07:27 AM Staff F, Licensed Practical Nurse (LPN) was observed administering Tylenol 650 milligrams (mg) by mouth for pain to Resident #51. A review of the Medication Administration Record (MAR) did not show medication was administered. A follow up interview with Staff F was conducted on 02/21/23 at 11:48 AM. Staff F, LPN stated she didn't know why the medication was not documented. Staff F was not able to produce documentation of the medication from the morning but was able to provide a nursing note written at 11: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed, and twenty-six errors were identified for five (#398, #395, #70, #63, and #31) of five residents observed. These errors constituted an 83.87% medication error rate.

Inspectors wroteBased on observations, interviews and record review the facility failed to 1) maintain drugs and biologicals used in the facility in a safe, secure, and orderly manner for three medication carts (Second floor East and [NAME] medication carts, and First floor [NAME] cart) of five medication carts as evidenced by insulin pens and insulin vials without documented opened-on dates, and 2) the facility failed to secure the contents of two (first floor west, second floor east) of five medication carts observed during survey.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure privacy during personal care for one (#60) resident out of 46 residents sampled.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one (Resident #59) of three residents sampled for accidents had an accurate and current Minimum Data Set related to the use and placement of an elopement prevention alarm.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure that the behaviors, outcomes, and non-pharmaceutical interventions were monitored for one (#396) out of five residents sampled for unnecessary medications.