The Highlands at Brighton

Inspectors wroteBased on interviews and record review, the facility did not ensure alleged violations involving resident-to-resident physical aggression were reported immediately to the Administrator and the New York State Department of Health for two (2) of four (4) residents reviewed (Resident #4 and Resident #5). Specifically, on 11/24/2025 at 6:00 PM, Resident #4 threw a cup containing ice at Resident #5 during a verbal altercation, striking Resident #5. The facility did not notify the Administrator until 11/28/2025 at 3:00 PM and did not report the incident to the New York State Department of Health until 12/02/2025 at 3:45 PM.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident's environment remained as free from accident hazards as possible for one (1) of five (5) residents reviewed (Resident #6). Specifically, the facility did not ensure consistent monitoring and documentation of Resident #6's self-administration of medications as ordered by the medical provider. The facility also did not ensure accurate accountability of medications available to Resident #6 after the resident reported ingesting multiple days' worth of medications.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 08/6/2025 to 08/13/2025, for four (4) (Medication Carts on Residential Units A, B, D, and E) of five (5) medication carts reviewed, the facility did not ensure that all drugs and biologicals were stored and/or labeled in accordance with currently accepted professional principles and regulations. Specifically, on the Residential E Unit, there were pre-poured medications for multiple residents and multiple loose medications in the medication cart. On the Residential A Unit, there were multiple loose pills in a medication cart, and an unlocked, unattended medication cart was observed. On the Residential D Unit, medication carts were left unlocked and unattended with medications sitting on top. On the Residential B Unit, a medication cart was left unlocked and unattended.

Inspectors wroteBased on observation, interviews, and record review conducted during a Recertification Survey from 08/06/2025 to 08/13/2025, for one (1) (Resident #1) of one (1) resident reviewed, the facility did not ensure the resident's right to privacy and confidentiality of their personal and medical records was maintained. Specifically, a computer stationed in a hallway on Residential Unit D was observed open, exposing Resident #1's personal and medical information; there were no staff members present to secure the information for nine (9) minutes. This is evidenced by the following:Resident #1 had diagnoses including chronic respiratory failure, diabetes, and methicillin resistant staphylococcus aureus infection (a bacteria that is resistant to a wide range of antibiotics). [...]

Inspectors wroteBased on interviews and record review conducted during a Recertification Survey from 08/06/2025 to 08/13/2025, for one (1) (Resident #90) of one (1) resident reviewed, the facility did not ensure an incident was thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, Resident #90 reported being touched on their leg and foot by a staff member, and the facility could not provide documented evidence that potential abuse, neglect, or mistreatment were ruled out. This is evidenced by the following:The facility policy Abuse, Neglect & Mistreatment, dated October 2024, included the residents shall be free from verbal, mental, sexual and physical abuse, corporal punishment and involuntary seclusion, mistreatment or neglect. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 08/06/2025 to 08/13/2025, for two (2) (Residents #5 and #57) of four (4) residents reviewed, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #5 required staff assistance with shaving and was observed on multiple occasions with a significant amount of facial hair. Resident #57 required staff assistance with showering and hair washing, there was no documented evidence the resident received a shower or had their hair washed for two (2) weeks, and their hair was uncombed and oily with a dry, flaky scalp over multiple days. This is evidenced by the following:1. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 08/06/2025 to 08/13/2025, for one (1) (Resident #57) of one (1) resident reviewed, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, Resident #57 had a medical order to wear a compression sleeve to their left arm and on multiple observations, did not have the compression sleeve in place. This is evidenced by the following:Review of the facility policy Splints/Braces, last revised October 2024, included, but was not limited to, nursing will add the device to the resident's care plan and Activities of Daily Living (ADL) Sheet/Care Card. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 08/06/2025 to 08/13/2025 for two (2) (Residents #69 and #81) of two (2) residents reviewed, the facility did not serve food in accordance with professional standards for food safety. Specifically, Resident Care Aide #1 was observed touching unwrapped pieces of graham crackers with their bare hands and the crackers were then consumed by Residents #69 and #81. This is evidenced by the following:The facility policy Hand Washing, dated June 2024, included hand washing was the most important component on infection prevention and should occur before and after contact with a resident or resident's environment. Hand washing with either commercially available hand sanitizer or soap and water was acceptable. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 08/06/2025 to 08/13/2025, the facility did not ensure the posted nurse staffing information included the required information daily, at the beginning of each shift, and was readily accessible to residents, staff, and visitors. Specifically, the posted nurse staffing information did not include the actual number of licensed (Registered Nurses and Licensed Practical Nurses) and unlicensed (Certified Nursing Assistants) nursing staff who were directly responsible for resident care during each shift. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey from 9/27/23 to 10/4/23, it was determined that for two (Resident's #21 and #85) of five residents reviewed for dignity, the facility staff did not promote and treat each resident with respect and dignity in a manner and an environment that promotes maintenance or enhancement of their quality of life. Specifically, Resident's #21 had their personal belongings in bedside drawers in their room opened and contents reviewed by staff without their permission or explanation as to what staff were looking for. Additionally, for Resident #85 the facility staff were heard discussing the resident's private and protected health information (also known as HIPAA-Health Insurance Portability and Accountability Act) in a setting where others could overhear. This is evidenced by the following: 1. [...]

Inspectors wroteBased on interviews, and record review, conducted during the Recertification Survey 9/27/23 to 10/4/23, it was determined that for one of one resident groups, the facility did not ensure that concerns and recommendations of the residents group relating to resident care and life in the facility were acted upon promptly. Specifically, the facility could not provide evidence that residents' voiced concerns in Residents Council meetings were investigated, and rationales or responses were provided to the residents. This is evidenced by the following: The facility policy, Grievances, dated August 2020, included that a grievance is defined as any alleged violation or dispute between a resident/family and the facility, including interpretation or application of the resident's [NAME] of Rights. [...]

Inspectors wroteBased on interviews, and record reviews conducted during the Recertification Survey 9/27/23 to 10/4/23, it was determined that for one (Resident #85) of three residents reviewed for elopement, the facility did not ensure an alleged elopement was thoroughly investigated. Specifically, Resident #85 left the facility unsupervised on 8/5/23 for an extended period of time, staff were unaware of the resident's whereabouts, and the incident was not investigated. This is evidenced by the following: The facility policy Elopement Prevention, dated August 2023, documented that elopement is when a dependent resident in a licensed facility leaves that facility without staff observation or knowledge of their departure. The Quality Assurance committee will review and discuss all elopement concerns when indicated. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey 9/27/23 to 10/4/23, it was determined that for two (Resident #56 and #99) of 30 residents reviewed for care planning, the facility did not develop a comprehensive, person-centered care plan for each resident that included services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being or any specialized services. Specifically, Residents #56's comprehensive Care Plan (CCP) did not address their status as a current smoker, and Resident #99's CCP did not address the resident's current skin issues. This was evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey 9/27/23 to 10/4/23, it was determined for one (Resident #19) of four residents reviewed for activities of daily living (ADLs), the facility did not provide the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #19 was observed on several days to be unshaven and had fingernails that were long and unclean. This is evidenced by the following: Resident #19 had diagnoses including dementia with behavioral disturbance, depression, and rheumatoid arthritis. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey 9/27/23 to 10/4/23, it was determined that for three (Residents #21, #34, and #85) of twelve residents reviewed for accidents, the facility did not ensure that the resident's environment remained as free of accident hazards as is possible. Specifically, Resident #21 was observed smoking under the non-sprinkler awning and within 10 feet of the building; Resident #34 had cigaarette butts on their person and discarded cigarette butts in their trash can in their room; and Resident #85 eloped from the facility and the facility did not reevaluate the resident's risk for elopement or develop a comprehensive care plan (CCP) that addressed the incident with follow up measures to prevent reoccurrence. This is evidenced by the following: 1. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 9/27/23 to 10/4/23, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not follow state and federal guidelines related to the cohorting of residents for two (Residents #101 and #8) of two residents reviewed for Transmission Based Precautions (TBP). Additionally, for three (Units B, C, and D) of five units observed for Infection Control (IC) practices, multiple staff from various disciplines were observed not wearing face mask or not wearing their face mask correctly, including on a unit with multiple confirmed COVID-19 positive cases. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey 9/27/23 to 10/4/23, it was determined that the facility did not post the nurse staffing information to include the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift, the posting was not consistently updated with staffing changes and it had not been posted according to the posting requirements. Specifically, there were no Registered Nurse (RN) hours posted, the information titled Staffing Levels was posted outside the Administration Office in the administrative hallway and not accessible to residents and visitors and the information had not been updated consistently for past two months. The finding is: [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, completed on 12/6/21, it was determined that for one of one main kitchen, the facility did not maintain equipment in safe operating condition. Specifically, the low temperature dishwashing machine and five of six bimetallic food thermometers were not working properly. This is evidenced by the following: Review of a facility policy, Thermostat Calibration, dated 4/16/15, included that the thermometer may be the single most important tool you have to protect food. To calibrate a thermometer, fill a container with ice. Add clean tap water until the container is full. Put thermometer stem into the ice water so that the sensing area is completely submerged. Wait until the indicator stops moving. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, completed [DATE], it was determined that for one (Resident #216) of 25 residents reviewed, the facility did not ensure that the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive would be honored. Specifically, the physician's orders did not match the resident's Medical Orders for Life Sustaining Treatment (MOLST) wishes. Review of the facility policy MOLST/Advance Directives dated as last reviewed on [DATE], revealed that a MOLST will be completed for all residents whether they wish for Do Not Resuscitate (DNR) or not. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, completed on 12/06/21, it was determined that for one (Resident #36) of two residents reviewed, the facility did not provide the necessary services to a resident who was unable to carry out activities of daily living (ADLs) to maintain good grooming and personal care. The issue involved a lack of nail care for a resident with diabetes. This is evidenced by the following: Resident #36 was admitted to the facility on [DATE] with diagnoses including a stroke, diabetes, and adult failure to thrive. The Minimum Data Set Assessment, dated 10/5/21, included the resident was cognitively intact and required extensive assistance of one staff member for personal hygiene. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey, completed on 12/6/21, it was determined that the facility did not ensure that all resident's environments remained as free from accidents as possible. Specifically, one (unit D) of five residential living units at the facility had water temperatures exceeding 120 degrees Fahrenheit (°F) in resident rooms. This is evidenced by the following: When observed on 12/1/21 at 1:57 p.m., the temperature of the hot water in the handwash sink located in resident room D16 was observed to be 122.4 °F using a [NAME] brand model 9842 digital thermometer. At that time, the Surveyor and the Director of Facility Services (DFS) went to the boiler room and it was observed that the in-line temperature gauge for outgoing water after the mixing valve read between 111°F and 112°F. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, completed on 12/6/21, it was determined for one of two residents reviewed, the facility did not provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice, and the resident's care plan. Specifically, Resident #61 did not receive oxygen (O2) according to physician orders. In addition, the resident's O2 tubing was dirty, and the humidifier bottle was empty and observed on the floor. This is evidenced by the following: The facility policy, Oxygen Therapy with Nasal Cannula dated May 2012, included that all orders for O2 therapy by the physician should include O2 appliance to be used and flow rate desired. The nasal cannula should be replaced every week, and the bubble humidifier to be replaced when empty. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey completed on 12/6/21, it was determined that for one (Resident # 29) of two residents reviewed the facility did not ensure appropriate hand hygiene and glove use when providing wound care and did not maintain appropriate infection control techniques related to soiled linens and dressing supplies. This was evidenced by the following: Resident #29 was admitted to the facility with diagnoses that included cauda equine syndrome (compressed nerves in the lumbar region), diabetes and a stage four (full thickness tissue loss with extensive destruction or damage to muscle, bone and supporting structures) pressure ulcer of the sacral (buttocks) area. The Minimum Data Set Assessment, dated 9/28/21, revealed the resident was cognitively intact and had one stage 4 pressure ulcer. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey completed on 12/6/21, it was determined that for one (Resident #9) of one resident reviewed the facility did not ensure that the resident or the resident's representative were notified in writing of the reason for the transfer/discharge to the hospital in a language they understand. Specifically, Resident #9 was transferred to the hospital and the facility could not provide evidence that a written notice of transfer was provided to the resident or the resident's representative per the regulation. This was evidenced by the following: Resident #9 had diagnoses that included anoxic (lack of oxygen) brain injury, chronic respiratory failure with ventilator dependence and hepatic encephalopathy (loss of brain function from liver disease). [...]

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey completed on 12/6/21 it was determined that for one (Resident #9) of one resident reviewed the facility did not ensure written notification of the facility's bed hold policy was provided to the resident and/or representative upon transfer to the hospital per the regulations. Specifically, neither Resident #9 or the resident's representative were provided information regarding the facility's bed-hold policy (including bed reserve policy) following a hospital admission. This was evidenced by the following: Facility policy, Bed Hold, dated 5/12/17, included that if a resident leaves the facility for a hospital stay, the facility is not required to hold a resident's specific bed, but will offer the first available appropriate bed. New admissions will be notified on the current policy for bed holds. [...]