Brighton Care Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents remained as free from accidents and hazards as possible. Resident #1, who had diagnoses of cerebral palsy (a movement disorder caused by brain damage during infancy), dorsalgia (back pain), adult failure to thrive, scoliosis (spine posture abnormality), dysphagia and osteoporosis, was admitted to the facility on [DATE]. Resident #1 was dependent on staff for transfers utilizing a Hoyer lift (mechanical lift). On 6/19/26 at 1:00 p.m. registered nurse (RN) #1 and certified nurse aide (CNA) #1 were transferring Resident #1 from her wheelchair to bed using the Hoyer power lift 700 using a large, full body sling. [...]

Inspectors wroteBased on observations, record review and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure dietary staff wore intact gloves over artificial fingernails with nail polish when working with exposed food; and, -Maintain the kitchen in a sanitary condition.

Inspectors wroteBased on record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure staff donned appropriate personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP); -Ensure staff followed appropriate infection control practices during vaccination administration; and, -Ensure staff disinfected vital signs equipment before and after each use.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#79) of four residents received treatment and care in accordance with professional standards of practice out of 42 sample residents. Specifically, the facility failed to correctly assess and care plan the progression of Resident #79's wound.

Inspectors wroteBased on record review and interviews, the facility failed to establish an effective antibiotic stewardship program to monitor for antibiotic use for two (#60 and #50) of seven residents reviewed for antibiotic use out of 42 sample residents. Specifically, the facility failed to effectively track and monitor the use of long-term antibiotics for Resident #60 and Resident #50.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to conduct a self-administration of medication assessment for 3 (Residents #6, #137, and #44) of 7 residents observed during medication administration. Specifically, Residents #6, #137, and #44 had medications left in their rooms without a self-administration of medication assessment being completed.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure 1 (Resident #145) of 3 residents reviewed for beneficiary notification was provided a Notice of Medicare Non-Coverage (NOMNC) a minimum of two calendar days prior to the last covered day of Medicare Part A services.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure 1 (Resident #30) of 2 residents reviewed for care plan participation had been invited to their care plan conference.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide sanitary administration of medications to prevent to the development and transmission of disease and infection for 1 (Resident #15) of 7 residents observed during medication administration.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure two (#5 and #211) of four out of 27 sample residents received care consistent with professional standards of practice to promote prevention and healing of pressure injuries. Resident #5 was dependent on staff for mobility, toileting, transfers and repositioning and was identified to be at risk for developing pressure injuries and had a history of pressure injuries acquired at the facility in the past. The facility failed to continue utilizing identified interventions to prevent the development of a new pressure injury for Resident #5 who previously had pressure injuries that were healed. This indicated the resident had the ability to heal. On 2/7/22 a pressure wound was discovered on Resident #5's coccyx measuring approximately 2 centimeters (cm) by 4 cm. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (#39) of three residents reviewed for falls out of 27 sample residents. The facility failed to timely and appropriately revise Resident #39's care plan and implement interventions including required extensive assistance with all activities of daily living and ambulation to and from the bathroom as documented in her 12/27/21 minimum data set (MDS) assessment. The facility failed to provide staff education and increase resident's supervision to prevent falls when she could not initiate staff assistance by using her call light. The facility failed to monitor the effectiveness of Resident #39's care planned interventions and modify the interventions to prevent her from falling. [...]

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure all drugs and biologicals were removed from use timely in one of two medication storage rooms. Specifically, the facility failed to: -Ensure expired intravenous (IV) antibiotic medications and expired tablets, cough syrup and topical cream were removed timely from a medication storage room refrigerator and storage cabinet.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to: -Ensure food and beverages stored in the unit refrigerators were covered, labeled and dated (two of two refrigerators); -Ensure that food stored was stored in the dry pantry appropriately; and, -Remove dented cans from service.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure that one (#9) of five residents reviewed, out of 27 sample residents were free from unnecessary psychotropic medications. Specifically, the facility failed to: -Provide the resident and/or the resident's family/representative sufficient information for their understanding of the intended/actual benefit and potential risk(s) or adverse consequences associated with the prescribed multiple antidepressant medications; -Ensure target behaviors were monitored and tracked for the use of multiple antidepressant medications and to justify the need for those psychotropic medications; -Reassess the need and provide a clinically pertinent explanation for duplicate pharmacological therapy for simultaneous use of two or more antidepressant medications; -Implement and document the use of non-pharmaceutical interventions; [...]