Brighton Place North

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to have sufficient licensed nursing staff 24 hours a day.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one kitchen.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to implement Enhanced Barrier Precautions (EBP- an infection control practice that uses personal protective equipment (PPE) to reduce the spread of multi-drug-resistant organisms (MDRO- common bacteria that have developed resistance to multiple types of antibiotics) for Resident (R) 4, who had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). The facility also failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems and chronic lung disease).

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents, with five reviewed for unnecessary medications. The facility failed to ensure as-needed (PRN) psychotropic medication had a stop date for Resident (R) 2, R5, and R26. The facility also failed to complete gradual dose reductions (GDR), with the physician's rationale of risk versus benefits, and if the GDR was clinically contraindicated for continued use of psychotropic medications for R2, R5, and R26.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents, with five reviewed for unnecessary medications. The facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities to the attending physician, the facility medical director, and the director of nursing for Resident (R) 2, R6, R5, and R26.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide a Bed Hold Notification for Resident (R) 4, who was hospitalized on [DATE] and 03/25/25, and R6 hospitalization on 06/26/25.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to submit a required discharge and re-entry Minimum Data Set for Resident (R) 4, who was hospitalized on [DATE] and returned to the facility on [DATE].

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the medication and biologicals for the residents were not outdated.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, interventions, and record review, the facility failed to implement protocols to avoid unnecessary and/or inappropriate antibiotic (medications used to treat infectious processes) use, adverse events, and multidrug-resistant organisms (MDRO- common bacteria that have developed resistance to multiple types of antibiotics), and to assess for infection using standardized tools and criteria before antibiotic use.

Inspectors wroteThe facility had a census of 33 residents. The facility had one kitchen. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 32 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 33 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure staff possessed the knowledge necessary to provide medications within acceptable standards of practice when staff pre-set nine residents' medications before administration time. This placed the residents at risk of receiving the wrong medications.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to discard an outdated insulin (a hormone that lowers the level of glucose in the blood) pen and failed to place an open date on two insulin pens (a disposable or reusable instrument, the size of a marker, used to deliver insulin) in the medication room. The facility failed to store medications properly, in their original packaging which included the medication name, dosage, and instructions for administration. This placed the residents at risk for medication errors and receiving ineffective medications.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise Resident (R)7's Care Plan to include a section with instructions to staff regarding R7's safety with smoking. This placed the resident at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 33. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the consultant pharmacist (CP) identified and reported the lack of a stop date for Resident (R) 24's as-needed (PRN) psychotropic (altering mood or thoughts) medication. This placed the resident at risk for unnecessary medication side effects.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure a 14-day stop date for Resident (R) 18's as-needed (PRN) antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment testing) and further failed to ensure R24's PRN lorazepam had a 14-day stop date, or a specified duration with a physician documented rationale for extended use. This placed the residents at risk for unnecessary psychotropic (alters mood or thought) medications. Findings Included: [...]

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents with two reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to assess, identify and implement an individualized bowel and bladder interventions for Resident (R)18 who had increased incontinence. This deficient practice placed the resident at risk for complications related to increased incontinence. Findings Included: [...]

Inspectors wroteThe facility identified a census of 43 residents. The sample included 12 residents, which included five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for Resident (R) 5 and R15 related to the lack of a 14 day stop date for as needed (PRN) antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions). This deficient practice placed R5 and R15 at risk for unnecessary medication administration thus leading to possible harmful side effects.

Inspectors wroteThe facility identified a census of 43 residents. The sample included 12 residents, which included five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician documented a duration not to exceed 14 days for use of as needed (PRN) antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment testing) and other mental emotional conditions). This deficient practice placed Resident (R)5 and R15 at risk for unnecessary medication administration thus leading to possible harmful side effects.