Brighton Place West

Inspectors wroteThe facility identified a census of 50 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral care and services for Resident (R) 1, who had moderate cognitive impairment as well as schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of violence and substance abuse. On 07/07/25, R1 began refusing to take his mental health medications and demonstrated increased behaviors. On 07/10/25, around 11:06 AM, the Social Worker spoke with R1's parental guardian, who shared concerns with R1's history of medication noncompliance, erratic behaviors, and history of substance abuse. [...]

Inspectors wroteThe facility identified a census of 48 residents. The sample included 13 residents with five residents reviewed for significant medication errors. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 21 remained free of significant medication errors. On 12/28/24 the facility received an order from R21's psychiatric provider to discontinue Clozaril (an antipsychotic medication used to treat major mental conditions that cause a break from reality) 25 milligrams (mg) in the morning. Licensed Nurse (LN) G discontinued both the 25 mg dose of Clozaril scheduled in the morning and the 500 mg dose of Clozaril at bedtime creating an abrupt discontinuation of the medication. [...]

Inspectors wroteThe facility had a census of 48 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 48 residents in the facility, who received their meals from the kitchen. This placed the residents at risk of foodborne illness.

Inspectors wroteThe facility had a census of 48 residents. The sample included 13 residents. Based on record review and interview the facility failed to deliver mail to facility residents on Saturdays.

Inspectors wroteThe facility had a census of 48 residents. The sample included 13 residents with three reviewed for discharge. Based on observation, interview, and record review the facility failed to provide written notice for facility-initiated transfers for Residents (R) 22, R23, and R20 or their representative when they were transferred to the hospital. The facility also failed to notify the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) of R22, R23, and R20's discharge. This placed the residents at risk of uninformed care choices.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents. Based on record review and interviews, the facility failed to ensure sufficient Licensed Nurse (LN) coverage and adequate weekend staffing. This placed the facility residents at risk for a decline and inadequate resident cares being completed.

Inspectors wroteThe facility identified a census of 49 residents. The sample include 13 residents. Based on record review and interviews, the facility failed to provide activities consistently on Saturdays. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing. Findings Included: - A review of the facility's Activity Calendar on Saturdays for April and May of 2023 revealed that on 4/1, 4/8, 4/15, 4/22, 4/29, 5/6, 5/13, 5/20, and 5/27 the schedule remained the same (10:00AM - Coloring, 01:30PM-Quiet Time, 03:00PM-Puzzles, and 06:00PM- Nightly News). On 05/11/23 at 11:01AM, Resident Council members reported the activities coordinator worked Sunday through Thursday. The council reported activities would often be missed on Saturdays due to low staffing. The council reported staff were busy and often not able to hold groups some weekends. [...]

Inspectors wroteThe facility identified a census of 49 residents. The sample include 14 residents. Based on observation, record review, and interviews, the facility failed to provide a certified activity professional. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing. Findings Included: - Upon request, the facility was unable to provide evidence the Activity Coordinator was certified. On 05/11/23 at 02:20PM Administrative Staff A stated that Activity Coordinator (AC) Z was on vacation, but the staff were covering the activities for the week. She stated she forgot that AC Z was not certified to provide activity. She stated the facility had not had a certified activities coordinator since October 2022. On 05/15/23 at 04:15PM Administrative Staff B stated she was the activity director until July 2022 and transition to another role in the facility. [...]

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents. Based on record review, and interviews, the facility failed to obtain pneumococcal (pneumonia infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination consents, declinations, or administration information for Residents (R)10, R29, R9 and R27. This deficient practice placed the residents at increased risk for pneumonia, and related complications.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents with two reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 33 and R41 were treated in a dignified manner. This deficient practice placed the residents at risk for decreased psychosocial well-being.

Inspectors wroteThe facility identified a census of 49 residents with 13 residents included in the sample. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) and Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) form 10123 which contained the required information for Resident (R) 32 and R99. This failure placed the residents at risk for decreased autonomy and impaired right to appeal.

Inspectors wroteThe facility identified a census of 49. The sample included 13 residents. Based on observation, record review and interview, the facility failed to provide written notice of transfer with the required information to Resident (R)32 and/or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R32.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to implement a physician order for daily weights to monitor for congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) for Resident (R) 29. This deficient practice placed R29 at risk of delayed treatment and untreated illness.

Inspectors wroteThe facility had a census of 49 residents. The sample included 13 residents with four residents reviewed for accidents. Based on observation, record review and interview, the facility failed to ensure chemicals were stored in a safe, secure manner. This deficient practice placed three cognitively impaired independently mobile residents at risk for preventable accidents and injuries. Findings Included: - On 05/10/2023 at 07:04AM an inspection of the facility revealed the laundry room door (right side) was propped open by a hanger. The room contained two bottles of disinfectant spray and a bottle of lemon scented furniture polish with the warning Caution- Keep Out of Reach for Children label indicating a poison ingestion risk. On 05/16/23 at 04:15PM Certified Nurse's Aide (CNA) M stated the laundry room should always be locked. [...]

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents with 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 monitoring hypertensive medication (class of medication used to treat high blood pressure) for Resident (R) 33 for failure to monitor heart rate and R29 for failure to administer as needed antihypertensive medication as ordered. This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects or harmful consequences.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to follow a physician order for monitoring of hypertensive medication (class of medication used to treat high blood pressure) for Resident (R) 33 for failure to monitor heart rate and R29 for failure to administer as needed antihypertensive medication as ordered. This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects or harmful consequences.

Inspectors wroteThe facility identified a census of 49 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to provide a system to ensure mail was consistently delivered on Saturdays for the residents. This deficient practice placed 49 residents at risk for decreased psychosocial wellbeing. Findings Included: - On 05/11/23 at 11:01AM, Resident Council members reported the facility often would not pass mail on Saturdays due to staff were not aware they were supposed to check the mailboxes and hand it out. The council reported mail would often be locked up until the following Monday. On 05/16/23 at 04:15PM Administrative Staff B stated mail should be collected on Saturdays by the charge nurse and secured in the administrative office until delivery to the residents. She stated the charge nurses should have a key to the mailbox. [...]

Inspectors wroteThe facility identified a census of 43 residents. The sample included 14 residents. Based on observation and interviews, the facility failed to provide a home like environment in the facility. This increased the risk for an institutionalized experience for affected residents.

Inspectors wroteThe facility identified a census of 43 residents. Based on observation, record review, and interview, the facility failed to ensure laundry staff failed to cover clothing racks when transporting clean linen/clothing through the facility as to prevent the spread of infection, and failed to ensure that facility staff measured and recorded water temperatures for the washing machine. This placed residents at risk of contaminants on clothing, and at risk for infection due to laundry not being laundered at appropriate water temperatures to clean and disinfect clothing.

Inspectors wroteThe facility identified a census of 43 residents. The sample included 14 residents, with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations were acknowledged and/or followed up for Resident (R) 20 and R10. This deficit practice had the potential for unnecessary medication use and possible unwarranted side effects.