Caretel Inns of Brighton

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of a Stage 3 pressure injury for one Resident (R57) of one resident reviewed for pressure injuries, resulting in wound treatments, increased pain and discomfort, and the potential for further wound deterioration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 02/11/26 at 8:14 AM observation of the kitchen two door cooler found a package of opened hot dogs with a facility marked date of 1/21/26. An interview at this time with Dietary Manager (DM) F found they use a seven-day discard for ready-to-eat, time/temperature control for safety foods. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of two Residents (R57 and R77) when appropriate durable medical equipment was not provided to accommodate their functional medical care needs.

Inspectors wroteThis citation pertains to intake #2677940Based on observation, interview and record review, the facility failed to ensure ancillary services were provided in a timely manner for three residents (R6, R20 and R64) of three residents reviewed for medically related Social Services.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent when two medication errors were observed (R3, R79) from a total of 29 opportunities resulting in an error rate of six percent. On 2/10/26 at 7:51 AM, Licensed Practical Nurse (LPN) C was observed for medication administration. R3 was ordered Miralax (medication to treat irregular bowel movements and constipation)17 grams. LPN C was observed pouring the medication granules into the measuring cap and was asked how to confirm the measure was 17 grams. LPN C was observed pointing to the inside of the measuring cap and indicated the white thread halfway in the white part of the cap cup was 17 grams. On 2/10/26 at 8:18 AM, LPN D was observed for medication administration. R79 was ordered Aspirin 81 milligrams (mg) oral tablet delayed release. [...]

Inspectors wroteThis citation pertains to Intake 2660312Based on interview and record review, the facility failed to implement a resident-centered intervention which required a two-person total assist for positioning onto a bedpan for one (R701) of one resident reviewed for falls, resulting in R701 falling to the floor, sustaining a left clavicle (collarbone) fracture, new pain and discomfort to their left upper extremity.

Inspectors wroteThis citation relates to Intake #MI00149608. Based on interview and record review, the facility failed to provide dignified care to answer call lights timely for two Residents (R804, R806) of five residents reviewed for dignity.

Inspectors wroteThis citation relates to Intake #MI00149071. Based on observation, interview, and record review, the facility failed to demonstrate professional standards of care related to one Resident (R807) of one resident reviewed for quality of care, when they did not provide a wheelchair cushion for a resident at risk for skin breakdown, resulting in pain and the potential for skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen, sub kitchen, and dining room counter resulting in the potential to affect all residents that consume food from the kitchen, sub kitchen, and dining room counter.

Inspectors wroteBased on interview the facility failed to implement an active water management plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP) resulting in the potential for water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program, resulting in the presence of spiders and drain (sewer) flies throughout the facility. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment, affecting multiple residents throughout the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently ensure medications were properly secured and that expired medications were discarded.

Inspectors wroteBased on interview and record review, the facility failed to complete an annual OBRA (Omnibus Budget Reconciliation Act) Level II Evaluation for one resident (R27) of one resident reviewed for PASARR (Preadmission Screen and Resident Review).

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain physician orders for one resident (R32) of one reviewed for oxygen use, and not monitoring oxygen delivery equipment for proper fit, resulting in the potential for respiratory distress, and undetected respiratory status changes.

Inspectors wroteThis citation pertains to intakes: MI00144321 and MI00144496. Based on interview and record review, the facility failed to notify the Licensed Practitioner and Resident Representative regarding an unwitnessed fall for one (R903) of two residents reviewed for accidents.

Inspectors wroteThis citation pertains to intakes: MI00144321 and MI00144496 Based on interview and record review, the facility failed to ensure timely and adequate assessment and investigation into an unwitnessed fall for one resident (R903)of two residents reviewed for falls, resulting in a delay of post-fall policy practices which included increased monitoring, initiate an investigation which delayed identification of an acute hip fracture resulting in transfer to the hospital for further evaluation and escalation of care, and increased pain.

Inspectors wroteThis citation pertains to intake # MI000142466. Based on record review and interviews, the facility failed to identify and monitor a change in condition for one resident (R610) resulting in a delay in a transfer to the hospital for unresponsiveness.

Inspectors wroteBased on interview and record review, the facility failed to report bilateral (B/L) facial bruising and right lower extremity (RLE) pain to the State Agency (SA) for one (R701) of one resident reviewed for injuries of unknown origin.

Inspectors wroteThis citation pertains to Intake #MI00141671 Based on observation, interview and record review the facility failed to ensure continuous nursing professional standards were practiced for signing documents and for one (R704) of two resident reviewed for dignity/respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate medication storage in four of four medication carts and for one resident (R172), of four residents reviewed for medication administration and storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's right to have non-male (direct) caregivers while at the facility for one (R171) out of two residents reviewed for dignity/respect.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal and mental abuse by Certified Nursing Assistant K (CNA K) for one resident (R231) of one residents reviewed for abuse/neglect/mistreatment.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for ensuring an allegation of mistreatment/verbal abuse was reported to the State Agency in accordance with section1150B of the Act for one resident (R231) of one residents reviewed for abuse/neglect/mistreatment.

Inspectors wroteBased on interview and record review, the facility failed to prevent resident access to an alleged perpetrator after an allegation of mistreatment was made and the investigation was still in process for one resident (R231) of one residents reviewed for abuse/neglect/mistreatment resulting in the increased potential for retaliation.

Inspectors wroteThis citation pertains to intake #MI00140216. Based on observation, interview and record review the facility failed to ensure staff followed proper Transmission Based Precautions (TBP) for one (R39) who was on Enhanced Barrier Precautions out of five residents reviewed for infection control.

Inspectors wroteThis citation pertains to intake: MI00139758. Based on interviews and record reviews the facility failed to timely implement treatment and interventions for an identified Moisture Associated Skin Damage (MASD) for one (R703) of three residents reviewed for pressure ulcers, resulting in the coccyx area to worsen to an identified wound with slough (Slough- is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) within four days of admission to the facility.

Inspectors wroteThis citation pertains to intake(s): MI00139758 & MI00138346. Based on interviews and record reviews the facility failed to complete a comprehensive nutrition admission assessment timely (R703) and provide a meal tray (R704) to two of four residents reviewed for nutrition.