Brightwood Center

Inspectors wroteBased on resident interview, staff interview and record review, the facility failed to ensure residents were free from sexual and psychosocial abuse perpetrated by another resident . This created an immediate jeopardy situation and put all residents at risk. Resident identifier's: #97 and #102. Facility Census: 111.

Inspectors wroteBased on record review and resident and staff interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to take actions related to allegations of abuse/neglect, when reported by staff. This had the potential to adversely affect all residents residing in the facility. The State Agency (SA) determined these failures caused Resident #97 to suffer sexual abuse and psychosocial harm. Due to the facility's failure to act on the allegation of sexual abuse when they were made aware not only placed Resident #97 at risk for sexual abuse and psychosocial harm but also placed the remaining 110 residents. The SA determined this constituted an Immediate Jeopardy (IJ) situation. Facility census: 111. [...]

Inspectors wroteBased on resident interview, staff interview and record review, the facility failed to ensure residents were free from sexual abuse by not implementing written policies for abuse and following policy and procedures to investigate abuse allegations. This was true for one(1) of six (6) residents reviewed for abuse. This failed practice has the potential to affect more than a limited number of residents. The situation was determined to be an Immediate Jeopardy situation due to all residents residing in the facility could experience serious actual or psychological harm if the facility did not immediately intervene. Resident identifier: #97. Facility Census: 111.

Inspectors wroteBased on observation, resident and staff interview the facility failed to provide the right to a safe, comfortable and homelike environment by not providing residents access to over the bed lights. This was a random opportunity of discovery. Facility Census: 111 Findings Include: a) On 5/19/25 at 12:45 PM a resident voiced her concern that she could not see very well while reading in her bed. She believed the light bulb needed to be brighter. Upon further investigation it was found that there was a light fixture over each resident's bed. There was a toggle switch to the right of each fixture. It is placed in a manner that requires the resident to get out of bed, walk to the head of the bed and reach the toggle switch in order to operate the light. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure posted nurse staffing information was accurate, by failing to update the posting. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 111.

Inspectors wroteBased on record review, resident interview, staff interview and observations the facility failed to ensure residents had a right to a dignified existence. This is in relation to their dining experience and failing to invite the residents and/or resident's representative to participate in the care plan meeting. These were random opportunities for discovery. Resident identifiers: #59, #89, #80, #6, #13, #109, #3, #14, #42 #58, #59, #109, and #42. Facility Census: 111 Findings Include: a) Resident #59 On 5/19/25 at 5:15 PM during the dinner meal observation in the Coral Dining Room it was observed that five (5) residents at table #1 were not served their meals at the same time. There were three (3) additional large tables seating five (5) at one table, and three (3) at the other two. There were also two (2) residents sitting at individual tables, alone. [...]

Inspectors wroteBased on staff interview, resident interview, observation and record review, the facility failed to provide suitable snacks for residents consistent with the residents plan of care. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifier's: # 74, #87, #10, and # 90. Facility Census: 111.

Inspectors wroteBased on record review, staff interview and observation, the facility failed to ensure food was stored and served in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 111.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to adhere to proper infection control practices by leaving food items being transported from the kitchen to the floor, uncovered and by failing to handle and transport soiled linens in a manner to prevent the spread of infection. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 111.

Inspectors wroteBased on investigation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. Furthermore, facility staff failed to notify maintenance or management of defective equipment promptly, thereby potentially exposing all residents in the facility to injury. Resident identifier: #24. Facility Census: 111.

Inspectors wroteBased on interviews and record reviews, the facility failed to afford the residents and their representatives the opportunity to participate in the care planning process and to be included in decisions and changes in care, treatment, and/or interventions. This was true for two (2) of two (2) residents interviewed. Resident Identifiers: Residents #42 and #70. Facility Census: 111. Findings Include: a) Resident #42 During an interview on 05/19/25, at 1:00 PM, the resident stated that he had not been invited to, nor given the opportunity to participate in, his care plan meeting. He further mentioned that his sister, who was his Medical Power of Attorney (MPOA), was not allowed to attend the meeting. Additionally, the resident's MPOA submitted a written statement that included the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify resident of treatment and healthcare information in accordance with his preferences. The facility further failed to ensure that each resident had the opportunity to exercise their autonomy regarding those things that were important in their life. This was true for one (1) of three (3) residents surveyed for choices. Resident Identifier: #70. Facility Census: 111. Findings Include: a) Resident #70 During an interview on 05/19/25, at 1:08 PM, Resident #70 expressed feeling unsafe because the facility does not keep him informed about his lab test results and other treatment outcomes. The resident, who is [AGE] years old and a veteran, also mentioned that he had not been invited to participate in his care plan meetings. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to give appropriate notices for discharges for residents who received Medicare Part A services. This was true for one (1) out of three (3) residents reviewed. Resident Identifier: #102. Facility Census: 111.

Inspectors wroteBased on record review, and interview, the facility failed to perform a thorough investigation and failed to take the necessary steps to correct the alleged violation. Resident identifier: #265. Facility Census: 111. Findings Include: a) Resident #265 A Facility Reported Incident (FRI) submitted on 10/21/24 at 3:15 Pm stated that Resident #265 had alleged that that she had to wait for three hours on 10/20/24 for incontinence care. The facility had performed an investigation and found the allegation unsubstantiated. Resident #265 was no longer at the facility. Record review on 05/22/25 at 10:00 AM revealed that Resident #265 had capacity and was classified as Dependent. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to implement the care plan for Resident #110 by failing to implement non-pharmacological interventions for pain and by failing to identify an acceptable level of pain. This was true for one (1) of 30 care plans reviewed during the survey process. Resident identifier: #110. Facility census: 111. a) Resident #110 During a review of Resident #110's care plan on 5/19/2025, the following was noted: Focus- (Resident #110's name) is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting. Date initiated-05/02/25. Goal- (Resident #110's name) will improve current level of function in:bathing, grooming/personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting by next review as evidenced by improved ADL scores. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to revise a care plan for a resident with ordered adaptive equipment. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier: #100. Facility Census: 111. Findings Included: a) On 05/19/25 at 05:44 PM, Resident #100 was given his drink during the dinner meal in a Sip-A-Mug cup. Resident #100's care plan stated to provide a [NAME] Cup. On 05/21/2025 at 03:00 PM, the Director of Nursing (DON) stated they changed the order yesterday for a Sip-A-Mug due to the straw used with a [NAME] Cup. The resident is currently ordered honey consistency thickened liquids. The DON confirmed the resident's care plan stated to provide a [NAME] Cup. [...]

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to ensure dependent residents received required assistance with Activities of Daily Living (ADLs), by failing to ensure Resident #110 was assisted to bed and Resident #42 received assistance with toileting and incontinence care. This was true for two (2) of five (5) residents reviewed for ADL care during the survey process. Resident identifiers: #110, #42. Facility census: 111.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the environment over which it had control was free from accident hazards. Namely, the facility failed to identify risks and hazards related to the resident's beds and failed to perform preventive maintenance to ensure that the beds were safe and functional. In addition, the facility's preventive maintenance program failed to identify the risks posed by defective or broken bed wheels and failed to include inspection, assessment, and maintenance of the bed wheels in the facility's preventive maintenance policy. Resident Identifier: Resident #24. Facility Census: 111. Findings Include: a) Resident #24 A Facility Reported Incident (FRI) on 04/10/25 stated that Resident #24 was injured when the resident's bed moved while the nursing assistant was providing care. [...]

Inspectors wroteBased on record review and resident and staff interview, the facility failed to control pain for Resident #110 by failing to implement non-pharmacological interventions for pain and by failing to identify an acceptable level of pain. This was true for one (1) of four (4) residents reviewed for pain during the survey process. Resident identifier: #110. Facility census: 111.

Inspectors wroteBased on record review and resident and staff interview, the facility failed to ensure Medically related social services were provided to Resident #51, related to a desired transfer to another facility. This is true for one (1) of one (1) residents reviewed for medically related social services during the survey process. Resident Identifier: #51. Facility census: 111.

Inspectors wroteBased on observation, resident and staff interview the facility failed to honor resident preferences for meals or provide an alternative vegetable. This was a random opportunity for discovery. Resident Identifiers: #75 and #80. Facility Census:

Inspectors wroteBased on observation, record review and staff interview the facility failed to provide adaptive devices during a meal. This was a random opportunity for discovery. Resident Identifiers: #89 and #100. Facility Census: #111 Findings Include: a) Resident #89 On 5/19/25 at 5:25 PM observation at the dinner meal found Resident #89 had a meal ticket that consisted of a sip a mug. She did not have a sip a mug provided with her meal. This was confirmed on 5/19/25 at 5:30 PM with Nurse Aide (NA) #110 at which time she commented I don't know if she still has an order for the sip mug. Review of her physicians orders reads: Regular/Liberalized diet Regular texture, standard thin liquids consistency, sip a mug per residents request. Her care plan read: Resident at increased nutritional risk d/t ETOH abuse, COPD, cerebral aneurysm may affect nutritional status/meal intake. Advanced age. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to accurately complete a smoking assessment for Resident #32. This was true for one (1) of five (5) residents reviewed for smoking. Resident identifier: #32. Facility census: 111.

Inspectors wroteBased on record review and resident and staff interview, the facility failed to deploy sufficient staff to meet resident care needs by failing to provide Activities of daily living (ADL) care for Residents #28, 24, and 81, while failing to meet state minimum staffing numbers on reviewed days. This has the potential to affect more than a limited number of residents. Resident identifiers: 28, 24, 81. Facility census:

Inspectors wroteBased on observation and staff interview, the facility failed to provide dignified dining experiences for residents eating in the dining room and their rooms. The facility failed to serve all residents seated at the same table at the same time. The facility also failed to sit down while feeding Resident #100 and #108. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: 100, 108. Facility census: 109.

Inspectors wroteBased on record review and staff interview the facility failed to provide information and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manner, complete neurological checks or accurately provide pain management. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. Resident Identifier: #27 and #80. Facility census: 109.

Inspectors wroteBased on observation and staff interview, the facility failed to complete temperature logs for food items being maintained on the steam table at meal service. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 109.

Inspectors wroteBased on resident interview, resident council meeting, and anonymous staff interviews, the facility failed to offer residents a nourishing evening/bedtime snack. This failed practice had the potential to affect an unlimited number of residents. Resident identifiers: #80, #48, #28, #13, #40, #72, #66, #48, #63, #50, #105, #78, #53, #55, #68, #19, and #11. Facility census: 109. a) Evening/Bedtime Snack During an interview on 04/22/24 at 3:34 PM, Resident #80 reported she was not offered an evening snack. A subsequent review of Resident #80's Significant Change in Status minimum data set (MDS), with an assessment reference date (ARD) of 03/29/24, indicated resident's Brief Interview for Mental Status (BIMS) score was 15. This score signified the resident was cognitively intact. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to store food in a safe and sanitary manner, and maintain sanitary equipment. This has the ability to affect more than a limited number of residents. Facility census:

Inspectors wroteBased on observation and staff interview, the facility failed to maintain proper infection control practices by failing to ensure soiled specimen collection devices were not left in rooms, resident trays were not placed in nourishment room refrigerators, dirty linens were not left in the floor, linen carts were not uncovered, and that items that could contaminate clean linen were not placed on linen carts. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 109.

Inspectors wroteBased on record review, resident, and staff interview the facility failed to honor a Resident choice for bathing. This affected one of one reviewed for choices, during the long-term care survey. Resident identifiers #66. Census 109.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two (2) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident Identifiers: #48 and #216. Facility census:

Inspectors wroteBased on observation and staff interview, the facility failed to safeguard the privacy of Resident #88's medical record. This was true for one (1) of 12 residents reviewed during medication administration. Resident #88. Facility Census: 109. Findings Include: a) Resident #88 On 04/24/24 at 1:46 PM, an observation was made during medication administration on the B hall. Licensed Practical Nurse (LPN) #38 was standing at the medication cart. LPN #38 was preparing to administer medication to Resident #88. At this time, Resident #12 requested LPN #38 assist her to the bathroom. Upon walking away from the medication cart, LPN #38 left the computer screen visible to anyone within the vicinity of the medication cart. On 04/24/24 at 1:51 PM, LPN #38 returned to the medication cart. LPN #38 was advised the computer screen was visible while Resident #12 was being assisted. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate Minimum Data Set (MDS) assessment for Resident #108. This was true for two (2) of 24 residents reviewed during the survey process. Resident Identifier: #108. Facility Census: 109. Findings Include: a) Resident #108 On 04/23/24 at 10:00 AM, the admission MDS dated [DATE] was reviewed. The review found Section O entitled Special Treatments, Procedures and Programs was incorrect regarding J1. Dialysis. Section J1 did not indicate the resident was receiving dialysis treatments. On 04/23/24 at 10:19 AM, Clinical Reimbursement Coordinator (CRC) #65 was notified. CRC #65 confirmed section J1 was incorrect. CRC #65 stated, we can send in a correction right away.

Inspectors wroteBased on medical record review and staff interview, the facility failed to update the care plan to reflect a change in activities of daily living (ADL) status for resident #80 and a change in Resident #108's need for assistance during meals. These were random opportunities for discovery. Resident identifiers: #80 and #108. Facility census: 109.

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to provide a resident who is unable to carry out activities of daily living (ADL)s the necessary services to maintain good grooming for Resident #28, by not shaving the resident twice a week, as requested by the resident, and by not providing nail care and assisting Resident #24 with meals. This was true for two (2) of four (4) residents reviewed for ADL care. Resident identifiers: 28, 24. Census 109.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain a safe and accident free environment as possible. This was a random opportunity for discovery. Resident Identifier: #58. Facility Census: 109. Findings Include: a) Resident #58 On 04/23/24 at 9:50 PM, a bottle of lubricating eye drops were found at Resident #58's bedside. The resident stated, I don't know how long they have been sitting there. On 04/23/24 at 9:52 PM, Licensed Practical Nurse (LPN) #92 was notified the eye drops were found at bedside. LPN #92 confirmed the eye drops should not have been left at bedside. On 04/24/24 at 9:20 AM, the Director of Nursing (DON) was notified of the incident regarding the eye drops found at bedside. The DON stated, medication should not be left at bedside.

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to manage Resident #5's chronic pain. This is true for one (1) of two (2) residents reviewed under the care area of pain. Resident Identifier: #5. Facility Census: 109. Findings Include: a) Resident #5 On 04/22/24 at 2:15 PM, an interview was conducted with Resident #5. The resident stated, I have had four (4) back surgeries .they won't give me pain medication .they say they are referring me to a pain clinic. On 04/22/24 at 5:00 PM, a record review was completed for Resident #5. The review found two (2) current physician's orders for the following: -- Tylenol Extra Strength 500mg (milligram) give two (2) tablets by mouth every 6 (six) hours as needed for general discomfort 1-4 (one to four) pain scale. Do not exceed 3 (three) gram within 24 hours. [...]

Inspectors wrote, Based on record review and staff interview, the facility failed to maintain professional standards of care for residents receiving dialysis. This was true for one (1) of two (2) residents reviewed under the care area of dialysis. Resident Identifier: #108. Facility Census: 109. Findings Include: a) Resident #108 On 04/22/24 at 6:40 PM, a record review was completed for Resident #108. The review found the resident receives dialysis on Tuesday, Thursday and Fridays. The resident's chair time is 10:30 AM. A review of the Dialysis Communication forms was completed on 04/24/24 at 9:30 AM. The following Dialysis Communication form was found to be incomplete: --04/06/24 pre-dialysis facility nurse's signature was missing On 04/24/24 at 10:30 AM, the Director of Nursing (DON) was notified. The DON confirmed the Dialysis Communication forms should be filled out completely.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure narcotic medications for Resident #91 were not misappropriated by failing to properly reconcile the narcotic medication count. This was true for one (1) of one (1) for pharmacy records during the survey process. Resident identifier: 91. Facility census: 91.

Inspectors wroteBased on observation and staff interviews, the facility failed to post accurate menus prior to meal times. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 109.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #22. This was true for one (1) of 24 residents reviewed during the survey process. Resident Identifier: #22. Facility Census: 109. Findings Include: a) Resident #22 On 04/22/24 at 5:18 PM, a record review was completed for Resident #22. The review found the Physician's Scope of Orders for Treatment (POST) form was not complete. The POST form was not signed or dated by the resident or the resident representative. On 04/22/24 at 6:41 PM, the Director of Nursing (DON) was notified of the incomplete POST form. The DON confirmed the form was missing the signature of the resident or the resident representative as well as the date. No further information was obtained during the survey process.

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to ensure the resident environment over which it has control is as free from accident hazards as possible. The facility failed to correct the identified issue of nurses placing resident medication in medicine cups, placing the medicine cups on the bedside table or over-bed tray, and walking away without waiting to see if the medication was taken. Resident identifiers: #13, #84, #15, #92, and #26. Facility Census: 114 a) General Dose Preparation and Medication Administration Policy Section 5 of the facility's General Dose Preparation and Medication Administration Policy reads, During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: - 5.10 Observe the resident's consumption of the medication(s). [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure each resident had the right to personal privacy and confidentiality of his or her personal and medical information. Staff failed to secure medical information from those who did not have a need to know, by leaving reports on the medication carts unattended, which contained personal and medical information for resident's care. The information was in plain sight of anyone passing by in the hallway. This deficient practice was identified through a random opportunity for discovery and had the potential to affect more than a limited number of residents. Census:

Inspectors wroteBased on observation, resident interview, staff interview and policy review the facility failed to serve all Residents residing in the same room at the same time. This was a random opportunity for discovery. Resident #34 was not afforded a dignified dining experience. Resident identifier: #34. Facility census: 108.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure one (1) of 28 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed correctly per directions specified by the [NAME] Virginia Center for End-of-Life Care. Resident identifier: #11. Facility census: 108.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence that a copy of a resident's Notice of Transfer/Discharge was sent to the Long-Term Care Ombudsman. This was true for one (1) of three (3) sampled residents reviewed for hospitalizations. Resident identifier: #64. Facility census: 108. Findings Included: a) Resident #64 A medical record review was completed on 08/23/22 at 2:33 PM. The record review revealed Resident #64 was transferred to the hospital on [DATE]. The record did not reflect the Notice of Transfer was sent to the Ombudsman. During an interview on 08/24/22 at 8:36 AM, the Administrator stated the facility had no evidence a Notice of Transfer had been provided to the Ombudsman. .

Inspectors wroteBased on record review and staff interview, the facility failed to provide resident-centered care and services, in accordance with professional standards of practice to meet each resident's needs. The facility failed to follow physician orders for the administration of insulin. This was true for two (2) of seven (7) residents reviewed for medications during the Long-term Survey Process Survey Process. Resident identifiers: #64 and #85. Facility census: 108.

Inspectors wroteBased on resident interview, observation, and staff interview, the facility failed to serve food that was palatable and at an appetizing temperature. This failed practice had the potential to affect a limited number of residents currently receiving nutrition from the facility's kitchen. Resident Identifiers: #1 and #79. Facility Census: 108. Findings Included: A) Resident #1 During an interview 08/22/22 at 11:45 AM, Resident #1 stated she ate in her room for meals and that the food is cold. On 08/23/22 at 12:51 PM, temperatures were obtained on the lunch meal tray for Resident #79. (Resident #79's tray was selected because it was the last tray to be served on the same hall as Resident #1. The following temperatures were obtained by the Dietary Manager using his thermometer: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items that were opened. This failed practice had the potential to affect a limited number of residents who are served food from the kitchen. Facility census: 108.