New Brighton Care Center

Inspectors wroteBased on interview and document review, the facility failed to develop and document a facility assessment that includes plans for the recruitment and retention of staff. This had the potential to affect all 43 residents. The provided facility assessment dated [DATE], included sections on how to obtain staffing records, a general staffing plan, staff assignments, staff training and competencies, however did not include a section on staff recruitment and retention. During interview on 11/18/25 at 4:20 p.m., the administrator confirmed the facility assessment did not include information on the facilities plan to maximize recruitment and retention of direct care staff. Facility policy for a facility assessment requested and not provided.

Inspectors wroteBased on interview and document review, the facility failed to submit complete and accurate direct care staffing information based on payroll and other verifiable and auditable data, for 1 of 1 quarters reviewed (quarter 3), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This had the potential to affect all 43 residents residing at the facility. Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D for April 1st to June 30th 2025, identified Excessively Low Weekend Staffing, No registered nurse (RN) Hours, and Failed to have licensed nursing coverage 24 hours a day. Report also triggered for One Star Staffing Rating. Dates identified for no RN coverage include 5/4/25, 5/31/25, 6/15/25, 6/22/2025, 6/28/25, and 6/29/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide ongoing communication to residents about their rights for 2 of 2 residents (R12, R28) who attended the resident council meetings. R12's admission minimum data set (MDS) dated [DATE], included R12 was cognitively intact and could understand others and make herself understood. R28's quarterly MDS dated [DATE], included R28 was cognitively intact and could understand others and make herself understood. Review of resident council meeting minutes for July 2025, August 2025, September 2025 and October 2025, failed to include information on resident rights. During a meeting about resident council on 11/19/25 at 1:30 p.m., R12 and R28 confirmed they did not discuss resident rights in the resident council meetings. R12 and R28 stated they do not remember going over the resident rights during admission. [...]

Inspectors wroteDuring observation, interview and document review, the facility failed to ensure food was prepared and distributed under sanitary conditions for 1 of 1 food trays dished up. During observation 11/19/25 starting at 11:10, cook (C - A was preparing the midday meal. C-A was wearing a pair of disposable gloves while setting up trays to be used for meal service. At 11:15 a.m., C-A left the kitchen by touching the door handle to open the door while keeping his gloves on. C-A returned less than 1 minute after holding a kitchen appliance with gloves still on his hands. C-A did not wash his hands or put new gloves on upon returning to the kitchen. C-A again opened the door with gloved hands and took a can of soup from a staff person to warm up for a resident. C-A did not wash hands or change his gloves. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure proper personal protective equipment (PPE) was used when providing cares for 1 of 1 resident (R37) reviewed for enhanced barrier precautions (EBP). Further, the facility failed to properly disinfect shared equipment between use for 1 of 1 glucometer (medical device used to check blood sugar levels) reviewed during medication administration. R37's admission minimum data set (MDS) dated [DATE], included R37 received nutrition through a parenteral or tube feeding source while a resident. R37's care plan dated 11/21/25, included R37 was on EBP due to his gastronomy tube (G tube or a surgically placed tube that provides direct access to the stomach for feeding, hydration or medications) . [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of potential abuse was reported timely to the State agency (SA), for 1 of 1 residents (R1) reviewed for an allegation of abuse.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of potential abuse for 1 of 1 residents (R1) who reported an allegation of potential abuse by staff.

Inspectors wroteBased on document review and interviews the facility failed to ensure the required staffing information was posted daily. This had the potential to affect all 41 residents residing in the facility and their visitors who may wish to review the information.

Inspectors wroteBased on interview and document review the facility failed to submit any data for staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (quarter 3), to the centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. Findings Include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D for quarter 3 2024 (April 1st through June 30th), identified no data had been submitted. As a result, the metric for excessively low weekend staffing, Registered Nurse (RN) hours and licensed nursing coverage was suppressed for the quarter. On 10/17/24 at 09:43 a.m., the human resources specialist (O)-B stated they were responsible for gathering and submitting the data for each quarter to CMS. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure the acting infection preventionist (IP) had completed specialized training in infection prevention and control. This had the potential to affect all 41 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure insulin flexpens and eye drops were appropriately labeled with an opened on date to prevent expired medications from being administered in 3 of 3 medication carts. In addition, the facility failed to ensure controlled substances were stored in a manner to reduce the risk of theft and/or diversion in 1 of 3 medication carts, and 1 of 1 medication refrigerators. This had the potential to effect all residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice-Centers for Medicare and Medicaid-10055 (SNFABN-CMS-10055) was provided to 2 of 3 residents (R194 and R195) reviewed for beneficiary notices.

Inspectors wroteBased on interview and document review, the facility failed to ensure a written notification of transfer was provided for 1 of 3 residents (R7) upon transfer to the hospital. In addition, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 1 of 3 residents (R7), reviewed for hospitalization. This had the potential to affect all residents transferred to hospital.

Inspectors wroteBased on interview and document review, the facility failed to provide a written notice of a bed hold at the time of transfer for hospitalization for 1 of 3 residents (R7) reviewed for hospitalization.

Inspectors wroteBased on interview and document review, the facility failed to ensure physician orders were followed for 1 of 1 residents (R7) reviewed for skin conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control measures when performing wound care for 1 of 1 residents (R25) reviewed for wound care.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 residents (R2, R3) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure proper sanitization of dishware used for meal preparation and resident service when 1 of 1 high-temperature commercial dishwashers was identified as not reaching adequate wash and rinse temperatures. In addition, the facility failed to store dishware in a manner preventing contamination. Further, the facility failed to ensure the ice dispensing machine was clean and free of excess mineral build up or cleaned on a regular schedule. This had potential to affect all 36 residents within the nursing home, staff, and visitors who consumed food from the main production kitchen and/or ice from the dining room ice machine. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure fans in the dish sanitization and storage area were maintained in a clean and sanitary manner to prevent dishware contamination. This had potential to affect all 36 residents within the nursing home, staff, and visitors who consumed food from the main production kitchen.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure hand hygiene was completed for 3 of 3 residents (R23, R25, R24) observed during wound cares. Furthermore, the facility failed to ensure hand hygiene was completed for 1 of 1 residents (R23) reviewed for toileting.

Inspectors wroteBased on interview and document review, the facility failed to ensure 5 of 5 residents (R1, R9, R18, R21, R27) were provided education regarding risks and benefits, offered, and/or received the pneumococcal vaccine in accordance with the Centers for Disease Control (CDC) recommendations. R1's Medical Diagnosis list dated 11/22/23, included lung disease, heart failure, and opioid dependence. The CDC's PneumoRecs VaxAdvisor indicated for patients aged 19-64 who have not received PCV15 or PCV20, with a risk factor of heart and lung disease and had a PCV13, Give one dose of PCV20 at least 1 year after PCV13. Or Give one dose of PPSV23 at least 1 year after PCV13. R1's Order Summary Report dated 11/22/23, included May receive Pneumovax if not already received unless contraindicated starting 11/2/23. R1's Immunization Report dated 11/22/23, indicated R1 refused the PPSV23 vaccine. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess residents for the ability to self administer medications for 1 of 1 resident (R2) reviewed for medications at bedside.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure effective collaboration between the facility and a contracted hospice organization which affected 1 of 1 resident (R13) reviewed for hospice services, and failed to ensure vascular wounds were assessed for 1 of 2 residents (R23) reviewed for wounds.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a resident (R2) was assessed to safely use and store a curling iron for 1 of 1 resident reviewed for accidents.

Inspectors wroteBased on interview and document review the facility failed to ensure coordination of dialysis care for 1 of 1 resident (R25) who required dialysis (treatment to filter blood when kidneys are no longer able).

Inspectors wroteBased on interview and document review, the facility failed to re-evaluate the continued use of an as needed (PRN) antianxiety medication every 14 days as required for 1 of 1 residents (R13) reviewed for PRN antianxiety medication.