Brighton Post Acute Care

Inspectors wroteBased on record review and interview, the facility failed to ensure physician visits were completed as required for three Residents (#32, #4 and #15) out of a total of 22 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and readily accessible for facility staff for four Residents (#8, #44, #32 and #42) out of a total sample of 22 residents. Specifically:1. For Resident #44 and #8, the facility failed to ensure the Physician and other licensed professionals' progress notes were documented in the Electronic Health Record (EHR).2. For Resident #42, the facility failed to ensure nursing staff accurately documented the administration of lidocaine pain patches.3. For Resident #32, the facility failed to accurately document the cleaning of an oxygen concentrator filter.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a call light was able to be utilized for one Resident (#15), out of a total of 22 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure attending care plan meetings was offered to one Resident (#44) out of a total of 22 sampled Residents. Specifically, the facility failed to ensure the Resident was notified of the care plan meetings or was offered to attend.

Inspectors wroteBased on observation, interview, and records reviewed, the facility failed to meet professional standards of practice for two Residents (#44, and #35) out of a total of 22 sampled residents. Specifically:1. For Resident #44, the facility failed to implement physician orders for fluid restrictions.2. For Resident # 35, the facility failed to implement physician's orders for fluid restrictions.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide supervision with meals for one Resident (#44) out of a total sample of 22 residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for three Residents (#44, #1, and #32) out of sample of 22 residents. Specifically:For Resident #44, the facility failed to obtain physician orders for oxygen use prior to administration. For Resident #1, the facility failed to obtain physician orders for oxygen use prior to administration. For Resident #32, the facility failed to clean the oxygen concentrator filter, resulting in a thick build-up of dust.

Inspectors wroteBased on observation, interview and record review the facility failed for one Resident (#42) of 22 sampled residents, to provide adequate pain relief. Specifically, did not remove the used patch and replace it with a new patch for two days, which resulted in the Resident experiencing mild pain, and the potential for the body to absorb excessive amounts of lidocaine. In addition, facility staff applied two patches when there was an order for only one patch, which also contributed to the potential for the body to absorb excessive amounts of lidocaine.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were stored as required for one Resident (#22), out of a total sample of 22 residents. Specifically, the facility failed to ensure that medications were not left at the bedside for Resident #22 while unsupervised by staff.

Inspectors wroteBased on observations, record review and interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment for four Residents (#61, #41, #59, and #32) out of a total sample of 17 residents. Specifically, 1. For Resident #61 the facility inaccurately coded no significant weight gain when there was one. 2. For Resident #41 and Resident #59, the facility inaccurately coded their ability to be understood. 3. For Resident #32, the facility inaccurately coded that the Resident was in a comatose state. Findings Include: 1. Resident #61 was admitted to the facility in November 2023 with diagnoses including stroke, heart disease, asthma and diabetes. Review of the medical record indicated the following weights: 2/27/2024 15:14 146.2 Lbs. (pounds) 3/5/2024 13:51 151.4 Lbs. 3/12/2024 12:11 147.0 Lbs. 3/19/2024 14:24 147.0 Lbs. 3/26/2024 16:26 149.0 Lbs. [...]

Inspectors wroteBased on observation, policy review and interview the facility failed to store medications in a safe manner, store medications in accordance with currently accepted professional principles and failed to follow manufacturer's instructions for storage. Specifically the facility failed to: 1. Store medication in secured (locked) locations, accessible only to designated staff in two medication carts on one of two units. 2. Store and label medications in accordance with currently accepted professional principles in one medication cart on one of two units. 3. Maintain temperatures in accordance with manufacturer specifications on one of two units

Inspectors wroteBased on record review and interviews, the facility failed to identify and complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#16), out of a total sample of 17 residents, when the Resident was discharged from hospice services.

Inspectors wroteBased on observation, record review, and interview, the facility failed to 1.follow the care plan intervention to prevent a fall with a fracture and laceration for one Resident #1.2. implement and develop appropriate interventions to prevent a fall with a fracture for one Resident (#35), 3. complete a fall investigation report after a fall for one Resident (#7), and 4. keep one Resident (#67) free from accidents/hazards after ingestion of lotion with subsequent hospitalization, . 5(a). For Resident #5, the facility failed to implement a scoop mattress intervention in a timely manner (b). have a bed alarm in good working condition out of a total sample of 30 residents.

Inspectors wroteBased on observations, policy review, and interview, the facility failed to 1.) ensure nursing staff disinfected reusable resident care equipment (a vital sign machine) between residents and 2.) ensure nursing staff disinfected a blood glucose monitor after use. 3.) maintain measures they have in place to prevent the growth of Legionella, specifically, failed to monitor and document weekly testing protocols.

Inspectors wroteBased on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 4 nurses observed made 4 errors out of 31 opportunities, resulting in a medication error rate of 12.9%. Those errors impacted 2 Residents (#11 and #63), out of 4 residents observed.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure controlled medications were locked appropriately, medications were stored in clean/sanitary conditions, medications were labeled/dated appropriately and medications that had a shortened expiration date were not available for use in two out of two observed medication carts and one medication storage room.

Inspectors wroteBased on resident group meeting, interview and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve nutritional value, flavor, palatability and at appetizing temperatures on two of two units.

Inspectors wroteBased on observation, record review and interview, the facility failed to notify the physician of a change in status for one Resident (#23) out of a total sample of 30 Residents. Specifically, the facility failed to notify the physician when the Resident was observed to have vomited significantly while in bed.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment, specifically, failed to address a chirping fire alarm.

Inspectors wroteBased on record review and interview, the facility failed to 1. investigate a bruise of uknown origin for one Resident (#35) and 2. failed to investigate injury of unknown origin (laceration to head) for one Resident (#34) out of a total sample of 30 residents.

Inspectors wroteBased on record review and interviews, the facility failed to provide a written notice of discharge prior to transferring Two Residents (#1 and #20) to the hospital, out of a total sample of 30 residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide a bed-hold notice upon transfer to the hospital for Two Residents (#1 and #20), out of a total sample of 30 residents.

Inspectors wroteBased on record review and interview, the facility failed to update the plan of care for one Resident (#67). Specifically, the plan of care was not updated after the Resident swallowed lotion and was hospitalized . 2. develop and implement a complete plan of care for a resident with a pace maker (a cardiac device used to control and monitor heart rate) for one Resident (#1), out of a total sample of 30 residents.

Inspectors wroteBased on record review and interview, the facility failed to 1. obtain weekly weights as ordered for one Resident (#25) and 2. failed to provide follow up on a pharmacy recommendation for one Resident (#47) out of a total sample of 30 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents, specifically, the facility failed to 1)provide assistance with showers for two Residents (#65 and #23) and 2) provide supervision with meals for one Resident (#23) out of a total sample of 30 Residents.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure staff obtained necessary podiatry (foot care) services for One Resident (#20) out of a total sample of 30 residents.

Inspectors wroteBased on record review and interview, the facility failed to 1. address a significant weight loss for One Resident (#25), and 2. implement a dietician recommendations to prevent a significant weight loss for one Resident (#34) out of a total sample of 30 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to obtain a physician's order for the use of a CPAP machine (a machine for Continuous Positive Airway Pressure to treat sleep apnea) for one Resident (#13) with a diagnosis of sleep apnea out of a total sample of 30 residents.

Inspectors wroteBased on policy review, observation and staff interview, the facility failed to ensure pharmaceutical services met the needs of each resident. Specifically, the facility failed to ensure an antibiotic kit was replaced by the pharmacy after being opened.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a diet to meet one Resident (#40)'s specific dietary needs, as indicated on the Resident's tray ticket, out of a total sample of 30 residents.

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure they maintained a complete and accurate medical record for two Residents (#18) and (#5) out of a total sample of 30 Residents. Specifically, 1. For Resident # 18, nursing failed to document showers given on the Activities of Daily Living (ADLs) flow sheets and 2. For Resident #5, the facility failed to complete documentation for monitoring a bed alarm on each shift as ordered.