Brighton Bay Center for Rehabilitation and Healing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review the facility failed to properly store medication in three out of five medication carts, on one of two nursing units, and ensure medication were stored separate from food in one of two medication storage rooms. Findings included: On 8/23/23 at 9:21 a.m. a medication cart on the second floor was observed to be unlocked. There were no staff in sight and a resident was sitting five feet from the cart. At 9:41 a.m. the medication cart remained unlocked. Two staff members, including a nurse, were observed walking past the cart and not locking it. Photographic evidence obtained. On 8/23/23 at 9:38 a.m., a white, oval tablet was observed on the floor in room [ROOM NUMBER] suite A. Photographic evidence obtained. On 8/23/23 at 9:40 a.m. an observation was made of an orange tablet inscribed with a letter M on the floor in front of the resident's bed in room [ROOM NUMBER] suite B. Photographic evidence obtained. On 8/23/23 at 10:04 a.m., an observation was made of an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with facility staff and residents, and facility policy review, the facility failed to ensure allegations of drug use by staff on facility premises, and allegations of staff reporting to work under the influence of drugs were investigated potentially impacting the health and safety of 114 residents within the facility's care. Findings included: On 08/23/23 at 12:53 p.m. an interview was conducted with a resident in room [ROOM NUMBER]. The resident stated the Certified Nurse's Assistants (CNAs) come to work smelling like marijuana. The resident said, That is not pleasant at all. I do not like the smell. The staff are impaired while caring for patients. The resident stated it was not just one incident. She stated she could not give names or state when the incidents occurred. The resident said, It is a culture here. Everybody knows about it including the administration. On 8/23/23 at 12:55 p.m., an interview was conducted with the former resident council president. He said, The facility sometimes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy review the facility failed to implement control measures to prevent the potential re-infection or transmission of scabies among residents in the facility related to four residents (#4, #10, #11, and #12) out of twelve sampled who were treated or exposed to scabies. Findings included: Review of medical records showed Resident #10 was seen by a dermatology practice on 8/16/23 and treated for scabies on 8/16 and 8/17/23 with oral and topical medications. Review of admission records showed Resident #10 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, dementia, and disorder involving the immune mechanism. Review of Resident #10's August Orders and Medication Administration Record (MAR) showed the following: -Ivermectin 3 milligram (mg.) Give 4 tablets at morning medication pass. Start date 8/16/23. End date 8/17/23. The MAR shows medication was administered on 8/17/23. -Permethrin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure 1) expired supplements and medications were discarded from three of the six medication carts, and 2) medications were stored appropriately for three residents (#50, #10, and #52) out of 43 sampled residents. Findings included: An observation was conducted, on [DATE] at 10:22 a.m., with Staff O, Licensed Practical Nurse (LPN) of the One Center medication cart. The observation revealed an opened bottle of Prostat Liquid Protein with 11/14 written on it. The staff member turned the bottle over and stated it was not expired until May. Staff O confirmed the manufacturer label instructed to discard the bottle 3 months after opening and it should have been discarded a few days ago. An observation on [DATE] at 10:32 a.m., was conducted with Staff M, LPN, of the One [NAME] medication cart. The observation revealed the following: - Levemir insulin pen, with no pharmacy label. A label was located under the pen on the bottom of the drawer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure an assessment for self-administration of medications was completed for two residents (#44 and #88) out of the 28 residents observed on the west hall of the first floor. Findings included: On 2/20/23 at 11:12 a.m., a bottle of eye drops was observed on the over-the-bed table in front of Resident #44 as the resident lay in bed. The resident stated the family provided them, they (the drops) were over on the counter and were used once a day. A review of Resident #44's physician orders, on 2/20/23 at 11:35 a.m., revealed the resident did not have an order to self-administer eye drops. The review of the assessments completed for the resident did not indicate the resident had been evaluated for the self-administration of medications. An observation on 2/22/23 at 12:08 p.m., was conducted with Staff N, Assistant Director of Nursing (ADON) of a bottle of eye drops and a tube of deep penetrating pain relief gel on Resident #44's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to do an ongoing re-evaluation of the need for a restraint for one resident (#43) out of one resident with a restraint. Findings included: An observation was made on 02/20/23 at 10:40 a.m. Resident #43 was observed to be in the common room sitting inside a PVC (lightweight plastic tubing) rolling chair, that wraps completely around the resident's waist and between her legs (known as a merry walker). A review of Resident #43's facesheet revealed she was admitted to the facility on [DATE] with medical diagnoses which include but not limited to unspecified dementia without behavioral disturbances, anxiety disorder due to known physiological condition, unspecified mood disorder, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, delusional disorder, muscle weakness, abnormalities of gait and mobility, difficulty in walking, unsteadiness on feet, lack of coordination, and a history of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to 1) develop a baseline care plan within 48 hours of admission; and 2) provide a written summary of the baseline care plan to the resident/resident representative for two residents (#367 and #214) out of 43 sampled residents. Findings included: The facesheet for Resident #367 indicated the resident was admitted for short term rehabilitative care on 10/1/22 and was discharged on 10/7/22. The facesheet included diagnoses not limited to unspecified osteomyelitis, Type 2 Diabetes with foot ulcer, and personal history of unspecified adult abuse. The progress notes for Resident #367 indicated a note on 10/1/22 at 6:59 p.m., that identified the resident arrived via wheelchair transport with an admitting diagnosis of exostectomy of left foot with wound vacuum (vac). The admission Data Collection Tool was completed at 3:12 p.m. on 10/3/22. The baseline care plan for Resident #367 was not available in either the closed record or the electronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to develop and implement care plans for three residents (#69, #55, and #103) of forty-three sampled residents. It was determined care plans were not developed and implemented related to dental/oral status for Resident #69, diabetic diagnosis and care for Resident #55, and smoking/ smoking safety for Resident #103. Findings included: On 2/20/2023 at approximately 2:00 p.m. Resident #69's was observed in the room with a family member. An interview with Resident #69's family member revealed she was the resident's Power of Attorney and makes medical decisions, but Resident #69 could make her daily choice decisions. Resident #69 was observed in her bed, and with head of the bed approximately forty-five degrees and the call light placed within her reach. The resident was observed in a private room, her television on, the over the bed table placed over her, with many personal belongings on it and all within her reach. Resident #69 was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility did not ensure 1) a discharge care plan was in place, 2) a discharge summary was completed, and 3) post care discharge plans were documented for two residents (#112 and #113) out of three residents sampled for discharge. Findings included: A review of a document titled, Face Sheet, printed on 2/22/23 showed Resident #112 was admitted to the facility on [DATE] and was discharged on 11/27/22. The document showed under discharge status the resident's return was not anticipated. The document did not indicate where the resident was discharged to. A review of a document titled, Physician Orders List, dated 11/17/22 showed there were no discharge orders for Resident #112. A review of a care plan with a start date of 11/22/22, noted active on discharge, showed Resident #112 did not have discharge planning goals indicated. A review of a document titled, Face Sheet, printed on 2/22/23 showed Resident #113 was admitted to the facility on [DATE] and was discharged on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews the facility failed to 1) ensure one resident (#103) smoked in the designated smoking area and was adequately assessed for smoking out of three residents sampled for smoking. Findings included: 1) An interview was conducted with Resident #103 on 02/20/23 at 9:55 a.m. she said, I am a smoker; I sleep with my most important items like my lighters because they keep getting stolen. I keep my important items in my bag and I sleep with it because if you get caught with cigarettes and lighters they will take them away from you. You can get your smoking stuff from the desk if you want. One night I got caught smoking in my room. They're not happy with me because I was smoking in my room but I thought I was at home and they told me I can't smoke in the room. An interview was conducted with Resident #103's roommate on 02/20/23 at 9:57 a.m. She stated Resident #103 smoked in the room with me in it and they caught her and they told her she cannot do that. Neither resident was observed to be on oxygen. A review of Resident #103's facesheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure 1) respiratory care was provided consistent with professional standards of practice related to oxygen levels not set per physician orders for one resident (#72), and 2) respiratory equipment was stored appropriately for four residents (#72, #10, #62 and #73) out of five residents sampled during two of four days of survey. Findings included: Resident #72 was admitted to the facility on [DATE] with diagnosis to include pneumonia unspecified, adult failure to thrive, acute kidney failure and unspecified atrial fibrillation. An undated Minimum Data Set (MDS) for Resident #72 showed the resident is dependent on staff for activities of daily living (ADL) with one-person physical assistance. An observation was conducted on 2/20/23 at 12:15 p.m. of Resident #72 who was observed to be in her watching television. The resident was observed to have a nasal cannula on with her oxygen flow rate set to 5.5 liters per minute (LPM). The resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and interviews the facility failed to ensure insulin administration was adequately and appropriately monitored for two residents (#74 and #55) out of 7 resident reviewed for unnecessary medications and insulin administration. Findings included: 1) A review of Resident #74's facesheet identified the resident was admitted on [DATE]. The facesheet included diagnoses not limited to Type 2 Diabetes Mellitus. A review of Resident #74's physician orders for 2/2023 included an order for Insulin Lispro 100 unit/milliliter (mL) pen (interchange). Inject subcutaneously (sub-q) per sliding scale three times daily, 70-140=0 units, 141-180= 1 unit, 181-200= 2 units, 221-260= 3 units, 261-300= 4 units, greater than 400= call MD (Medical Doctor) . The order did not identify how much insulin Resident #74 should be administered for a blood glucose of 201-220 or if the residents blood glucose level was between 301 - 399. A review of Resident #74's Medication Administration Record (MAR) identified the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure behavioral/side effect monitoring was conducted for psychotropic medications for one resident (#74) out of five residents sampled for unnecessary medications administration. Findings included: An observation, on 2/22/23 at 11:45 a.m., identified Resident #74 was lying in bed with eyes closed. A review of Resident #74's facesheet indicated the resident was admitted on [DATE] for short term skilled nursing and rehabilitative care. The facesheet identified diagnoses that included but not limited to Type 2 Diabetes Mellitus, unspecified anxiety disorder, other seizures, and unspecified single episode major depressive disorder. A review of the active Physician Orders for Resident #74 indicated the resident received the following psychotropic medication: - Lorazepam 0.5 milligram (mg) orally three times a day. - Venlafaxine extended release 225 mg orally daily - trazodone 50 mg at bedtime - Divalproex 250 mg every morning and bedtime…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed with four errors identified for two residents (#51 and #17) of seven residents observed. These errors constituted a 14.29% medication error rate. Findings Include: 1. On 02/21/23 at 07:27 AM Staff F, Licensed Practical Nurse (LPN) was observed administering Tylenol 650 milligrams (mg) by mouth for pain to Resident #51. A review of the Medication Administration Record (MAR) did not show medication was administered. A follow up interview with Staff F was conducted on 02/21/23 at 11:48 AM. Staff F, LPN stated she didn't know why the medication was not documented. Staff F was not able to produce documentation of the medication from the morning but was able to provide a nursing note written at 11:15 AM assessing the effectiveness of the medication. Staff F stated, The original administration time may not show up except as medication follow up assessment. 2. Staff G, LPN prepared the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed, and twenty-six errors were identified for five (#398, #395, #70, #63, and #31) of five residents observed. These errors constituted an 83.87% medication error rate. Findings included: 1. On 6/2/21 at 10:11 a.m., an observation of medication administration with Staff Member T, Licensed Practical Nurse (LPN), was conducted with Resident #398. Staff T was observed administering the following medications: - Clopidogrel 75 milligram (mg) orally - Glipizide 5 mg orally A review of the Physician Orders for Resident #398 revealed the above medications were scheduled to be administered at 9:00 a.m. and the following medication orders: - Clopidogrel 75 mg orally once a day - Glipizide 5 mg orally once a day At 10:23 a.m. on 6/2/21, Staff T noted the medications, after the administration, as it was a late administration, then after a computer glitch she reentered the medication comment as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review the facility failed to 1) maintain drugs and biologicals used in the facility in a safe, secure, and orderly manner for three medication carts (Second floor East and [NAME] medication carts, and First floor [NAME] cart) of five medication carts as evidenced by insulin pens and insulin vials without documented opened-on dates, and 2) the facility failed to secure the contents of two (first floor west, second floor east) of five medication carts observed during survey. Findings included: 1) On 6/4/21 at 12:18 p.m. an observation of the medication cart for the Second-Floor East hall was conducted. Staff L, Licensed Practical Nurse (LPN) was present during the observation. In the top left drawer of the cart, a Levemir FlexTouch pen was observed stored in a bag, with no open or expiration date documented. A Kwikpen of Lispro insulin was stored in a bag without an opened-on date. A Novolin 70/30 Flexpen was observed with no open date documented. An open Levemir multi-dose vial (MDV) was observed with an open date of 3/23/21, and a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure privacy during personal care for one (#60) resident out of 46 residents sampled. Findings included: Resident #60 was observed from the hallway, on 6/3/21 at 6:11 a.m., standing up between an over-the-bed table and the bed, facing the door and not wearing any undergarments. Staff Member S, Certified Nursing Assistant (CNA), was observed standing to the side of the resident, bent over at the waist, and performing peri-care for the resident. As this writer introduced herself to the nurse who exited the resident room close to Resident #60's room, Staff S looked up, saw the writer standing in the hallway with the nurse, and exclaimed, oh no, reached over and shut the resident's door. Resident #60 was admitted on [DATE]. The Face Sheet included diagnoses not limited to Chronic Obstructive Pulmonary Disease (COPD) and Major Depressive Disorder (MDD). The Annual Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one (Resident #59) of three residents sampled for accidents had an accurate and current Minimum Data Set related to the use and placement of an elopement prevention alarm. Findings included: A review of Resident #59's Face Sheet, revealed a current admission date of 09/11/2015 with medical diagnoses of viral pneumonia, muscle weakness, unspecified mood affective disorder, and chronic obstructive pulmonary disease. Resident #59's MDS [Minimum Data Set] 3.0 Nursing Home Quarterly . dated 03/15/2021, revealed under Section C: Cognitive Patterns a Brief Interview for mental Status score of 14; indicating an intact cognition. Under Section G: Functional Status, it was revealed Resident #59 required extensive assistance with one-person for transfers, dressing, and personal hygiene. Resident #59 has a mobility device of a wheelchair. A review of Resident #59's Physician Order Report, revealed an active general order, dated 11/25/2019-Open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure that the behaviors, outcomes, and non-pharmaceutical interventions were monitored for one (#396) out of five residents sampled for unnecessary medications. Findings included: Resident #396 was admitted on [DATE]. The Face Sheet included diagnoses not limited to mild recurrent Major Depressive Disorder and a history of falling. An observation, on 6/1/21 at 10:52 a.m., Resident #396 was observed sitting in a chair next to the resident's bed. On 6/4/21 at 12:06 p.m., the resident was observed sitting up in bed watching television, and with a walker at the bedside. Resident #396's Medication Administration History for June 2021 indicated the resident was receiving the following psychotropic medications: - Aripiprazole (Abilify) 15 milligram (mg) tablet once a day for depression, started 5/28/21. - Sertraline (Zoloft) 50 mg tablet once a day for depression, started 5/28/21. The Medication History, printed on 6/2/21 at 2:04 p.m., for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.