Brightmoor Nursing Center, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and a review of the facility policy titled Abuse, Neglect and Exploitation, the facility failed to ensure that one of three sampled residents (R) (R6) was free from abuse.Findings included:A review of the electronic medical record (EMR) revealed that R6 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, coronary artery disease (CAD), hypertension, benign prostatic hyperplasia, hyponatremia, and hyperlipidemia. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R6 presented with a Brief Interview for Mental Status (BIMS) score of three, indicating a severe cognitive deficit. A review of the EMR revealed that R6 was discharged to another facility on 1/30/2026. A review of the EMR revealed that R5 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, non-traumatic brain dysfunction and dementia. A review of the admission MDS assessment dated [DATE] revealed that…

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, staff interviews, and review of the facility's policies titled Food Safety and Sanitation, the facility failed to ensure proper food labeling, dating, and storage, and failed to ensure food items were not available for resident consumption past their expiration date. These deficient practices had the potential to place the 118 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include:Review of the facility's policy titled Food Safety and Sanitation, dated 2021, revealed the Food Storage section included, All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored.When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food.Leftovers are used within 72 hours (or discarded). Note: 2017 Federal food code guidelines allow 7 days for food safety, with the day of preparation counted as day 1 of the 7 days, and then the food is discarded. Check local and state…

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 staff interview, record review, and review of the facility policy titled Resident Rights, the facility failed to obtain consent from the resident or responsible party (RP) for the use of psychotropic medication treatment for two of five residents (R) (R16 and R21) sampled for the use of unnecessary medications. This deficient practice had the potential to place R16 and R21 at risk of medical complications. Findings include:Review of the facility policy titled Resident Rights, revised December 2016, revealed the Policy Interpretation and Implementation: section included, 1. Federal and state laws guaranteed certain basic rights to all residents of this facility. These rights include the Residents to . P. Be informed of, and participate in, his or her care planning and treatment. 1. Review of the admission Record for R16, located under the Profile tab of the electronic medical record (EMR), revealed R16 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to,…

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, staff and resident interviews, and review of the facility's policy titled Self-Administration of Medications, the facility failed to assess one of 48 sampled residents (R) (R8) for the ability ot safely self-administer medications before leaving medications at the bedside. This deficient practice had the potential to place R8 at risk of overmedicating and medical complications. Findings include: Review of the facility's policy titled Self-Administration of Medications, revised December 2012, documented Policy Statement: Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. 1. Policy Interpretation and Implementation: As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner…

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 staff interviews, record review, and review of the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to protect one of 49 sampled residents (R) (R75) rights to be free from verbal abuse by another resident (R49). This deficient practice had the potential to place R75 at risk of a diminished quality of life.Findings include:Review of the facility's policy titled Abuse, Neglect, and Exploitation, revised 6/14/2024, included It is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse, or misappropriation of resident property. We believe that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusions. The Definitions section included, . 2. Verbal Abuse is defined as any use of oral, written, or gestured language that willfully includes sparing and derogatory terms to residents or their families, or within hearing distance, regardless of their…

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 staff interviews, record review, and review of the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to ensure a thorough investigation was conducted in a timely manner following an allegation of resident-to-resident verbal abuse involving two residents (R) (R75 and R49) from a sample of 49. Findings include:A review of the facility's policy Abuse, Neglect, and Exploitation, revised 6/14/2024, revealed the Investigation section included, . 4. Interviews will be conducted all pertinent parties. Written signed statements from any involved parties will be obtained and notarized, if possible. Statements will be gathered from the suspect person making accusations resident involved, reliable resident who may have witness the incident and any other persons who may have some information identify any possible conflicts between witnesses. 5. Past performances and/or previous incident of involved parties will be evaluated. Review of schedules and assignments showing when and where…

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 observation, staff interviews, record review, and review of the facility policy titled Care Plan-Comprehensive, the facility failed to develop a comprehensive person-centered care plan for two of 48 sampled residents (R) (R109 and R14). This deficient practice had the potential to place R109 and R14 at risk of unmet needs, medical complications, and a diminished quality of life. Findings include:Review of the facility policy titled Care Plan-Comprehensive, last revised October 2010, revealed that the facility's interdisciplinary and care plan teams would develop and maintain a comprehensive care plan for each resident, which would incorporate identified problems.1. Review of the admission Minimum Data Set (MDS) assessment for R109, dated 10/11/2025, revealed that Section H (Bowel and Bladder) documented that R109 had an indwelling urinary catheter.Review of the Order Summary Report for R109 revealed active orders for an indwelling urinary catheter and catheter care.Review of the care plan for R109 revealed no care plan for the indwelling urinary catheter. Observations 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, observation, and review of the facility's policy titled Hazard Communication Program, the facility failed to ensure that one of 49 sampled residents (R) (R135) rooms was free from accident hazards. This deficient practice had the potential to place R135 at risk of avoidable accidents and to diminish its quality of life. Findings include:Review of the facility's policy titled Hazard Communication Program revealed the Policy Statement section included, The purpose of the hazard communication program is to ensure that the hazards of all chemicals used in this facility have been classified and that the information concerning the hazard is communicated to employees. Review of the electronic medical record (EMR) revealed R135 was admitted on [DATE] with diagnoses including unspecified anxiety disorder and unspecified rheumatoid arthritis.Review of the Quarterly Minimum Data Set (MDS) for R135, dated 11/24/2025, revealed Section C (Cognitive Patterns) documented a Brief…

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, staff interviews, record review and review of the facility's policies titled Security of Medication Cart, Administering Medications and Storage of Medications, the facility failed to lock one of six medication carts, remove expired medication from one of two medication rooms and failed to place open dates on blood glucose strips in one of six medication carts. This deficient practice had the potential to place residents at increased risk of medical complications. Findings include: Review of the facility's policy titled Security of Medication Cart, revised April 2007, documented Policy Interpretation and Implementation: When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.Review of the facility's policy titled Administering Medications, undated, documented Policy Interpretation and Implementation: 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.Review of 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, staff interviews, and review of the facility's policies titled Infection Control and Handwashing/Hand Hygiene, the facility failed to implement infection control protocol by not practicing hand hygiene between glove changes. This deficient practice had the potential to place residents at risk of infections due to cross-contamination. The facility census was 119. Findings include:Review of the facility's policy titled Infection Control, revised December 2012, documented Purposes of Infection Control Programs: The major purposes of Infection Control Programs in the nursing facility are to minimize the effects of infections on residents and employees, and to educate the staff. A successful Infection Control Program requires an underlying commitment and facility-wide participation. It should not just be seen as a way to meet paperwork requirements but as a way to analyze and use information effectively to improve care and prevent problems.Review of the facility's policy titled Handwashing/Hand…

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 and staff interviews, the facility failed to maintain a clean, sanitary environment related to dusty vent covers in four rooms on one hall, (rooms 112, 113, 114, and 115) with the potential to affect eight residents in these four rooms. Findings included: A policy for environmental services and cleaning was requested, but one was not provided. Observations during the initial tour and screening of residents on 5/2/2023, and subsequent observations on 5/3/2023 and 5/4/2023, revealed a build-up of dust on the ceiling vent covers in the bathroom of Room (Rm) 112, RM [ROOM NUMBER], RM [ROOM NUMBER], and RM [ROOM NUMBER] as follows: Observation in room [ROOM NUMBER] on 5/2/2023 at 10:27 a.m. and 5/3/2023 at 9:10 a.m. revealed a dusty vent in the bathroom. Observation in room [ROOM NUMBER] on 5/2/2023 at 10:37 a.m. and 5/3/2023 at 1:00 p.m. revealed a dusty vent in the bathroom. Observation in room [ROOM NUMBER] on 5/2/2023 at 10:42 a.m. and 5/3/2023 at 8:20 a.m. revealed a dusty vent in 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.

Based on observation, staff interviews, record review, and review of the facility's policy titled, Care Planning-Interdisciplinary Team, the facility failed to follow/develop the comprehensive care plan for two of eleven residents (R) (#18, #176) reviewed for oxygen therapy. Findings include: Review of the undated policy provided by the facility titled, Care Planning-Interdisciplinary Team, policy interpretation and implementation revealed comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). 3. The IDT includes but is not limited to a. attending physician; b. registered nurse; c. nursing assistant; d. food and nutrition services staff; e. resident or resident's representative; f. other staff as appropriate. 1. Record review of the most recent quarterly Minimum Data Set (MDS) for R#18 dated 3/14/2023 revealed in section J-health conditions included shortness of breath (SOB), section O-special treatment, procedures, and programs included oxygen. Record review of the care plan R#18 revealed a goal and…

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, staff interviews, and record review the facility failed to follow the physician's order for one of eleven residents (R) (#18, #176) reviewed for receiving oxygen therapy. Findings include: Observations on 05/02/2023 at 01:22 p.m., 05/03/2023 at 01:44 p.m., and 05/04/2023 at 11:21 a.m. revealed R#176's nasal cannula was operating at the rate of 3LPM while no orders for oxygen were found in the medical record. Observation and interview 5/4/2023 at 2:27 p.m. with Licensed Practical Nurse (LPN) AA confirmed the care plan did not reveal information involving respiratory care utilizing oxygen via nasal cannula at 3LPM. Record review of the most recent MAR & TAR for R#176 dated 5/4/2023 at 12:55 p.m. revealed no instructions for the administration of oxygen. LPN AA confirmed that R#176's oxygen was being delivered to R#176 at three LPM and did not have a physician's order for this medication. LPN AA reported that she had not checked her O2 settings. Interview on 5/4/2023 at 12:58 p.m. with Director of Nursing (DON) revealed her expectation of nurses was to ensure…

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.