Brighton Cornerstone Group, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and facility policy review, the facility failed ensure residents had the right to be informed of, and participate in their treatment by failing to inform residents and/or their representatives in advance of the risks and benefits of psychotropic medication use prior to administration, which affected 5 (Residents 2, 20, 4, 6, and 5) of 5 residents reviewed for unnecessary medications.The findings include: Review of a facility policy titled, Antipsychotic Medication Use, revised in March 2015, indicated, Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. The policy revealed that it did not address discussing the risks and benefits of antipsychotic use with residents or their representative prior to administration. 1. An admission Record indicated the facility admitted Resident #2 on 11/22/2019.…

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, interview, record review, review of facility policy and manufacturer instructions, the facility failed to ensure a medication error rate of less than 5 percent (%). There were six errors out of 26 opportunities, which yielded a medication error rate of 23.08%, which affected 2 (Resident 36 and Resident 15) of 8 residents observed during medication administration.The findings include: A facility policy titled, Administering Medications, revised December 2012, indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The policy specified, 3. Medications must be administered in accordance with the orders, including any required time frame. Further review revealed, 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. An admission Record indicated the facility admitted Resident #36 on 04/12/2022. According to the admission Record, the resident had 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.

Based on interview, record review, and facility policy review, the facility failed to ensure 1 of 2 sampled residents (R14) reviewed for beneficiary notifications was provided a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) prior to the end of covered Medicare Part A services.The findings include: An undated document provided by facility staff titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC), indicated, A Medicare provider or health plan (Medicare Advantage plans and cost plans collectively referred to as 'plans') must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The policy continued, The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Resident 14's admission…

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, interview, and record review, the facility failed to provide necessary activity of daily living (ADL) care for 1 of 1 sampled resident's (Resident 12) reviewed for ADL care. Specifically, the facility failed to offer to shave Resident 12's facial hair. The findings include: An admission Record indicated the facility originally admitted Resident 12 on 03/03/2025 and readmitted the resident on 06/03/2025. According to the admission Record, the resident had a medical history that included diagnoses of left humerus fracture, chronic obstructive pulmonary disease (COPD), asthma, diabetes mellitus, peripheral vascular disease, hypertension, gastroesophageal reflux disease (GERD), chronic pain, major depressive disorder, morbid obesity, anxiety disorder, dysphagia, and diverticulosis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/01/2025, revealed Resident 12 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated that the resident required set-up or clean-up…

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, interview, record review, and facility policy review, the facility failed to ensure staff implemented Enhanced Barrier Precautions (EBP) and followed infection prevention and control practices for 1 (Resident 29) of 1 resident's reviewed for tube feeding. The findings include:A facility policy titled, Enhanced Barrier Precautions, updated 04/05/2024 revealed, It is the policy of this facility that Enhanced Barrier Precautions in conjunction with standard precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO, or residents with '[sic] infection or colonization with a CDC [Centers for Disease Control and Prevention]-targeted MDRO when Contact Precautions do not otherwise apply. The policy revealed, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce…

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, interview, record review, and facility policy review, the facility failed to cover, store and serve food in accordance with professional standards for food service safety which had the potential to affect 36 of the facility's 36 residents who consumed food from the kitchen. Observation of the kitchen revealed food items stored in the refrigerator and freezers that were not covered and exposed to air, and which were outdated and not rotated to ensure older items were used first. Further observation of the dry pantry storage revealed two large bins, one filled with cornmeal and a second filled with flour which were undated to indicate when they were opened or when the items should be discarded. The findings include: Review of the facility policy titled, Food Receiving and Storage, revised 07/2014, revealed foods were to be received and stored in a manner that complied with safe food handling practices. Continued review revealed dry foods in storage bins were to be removed from original packaging, labeled and dated with the use by date, and be rotated using 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 interview, record review, and review of the facility staffing schedules, it was determined the facility failed to ensure the services of a Registered Nurse (RN) were utilized for at least 8 consecutive hours a day, 7 days a week as required. Review of the facility's staffing schedules revealed the facility failed to provide eight consecutive hours of RN coverage for 15 days between 07/27/2024 and 09/29/2024. This failure affected all persons residing in the facility during those 15 days. The findings include: Review of the facility's, Facility Assessment Tool: Staffing Plan dated 11/01/2022, revealed the facility should have one Registered Nurse (RN) as the Director of Nursing (DON) full-time days, and at least one RN or Licensed Practical Nurse (LPN) for each shift. Continued review revealed the Facility Assessment Tool further noted if more than one new (resident) admit or readmit occurred on a shift, then the facility should consider bringing in another licensed nurse for at least four hours of a shift to assist. Review of the facility's Payroll-Based Journal (PBJ)…

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, interview, record review, and facility policy review, it was determined the facility failed to ensure all drugs were labeled in accordance with professional standards. Observation of the front hall medication room revealed a vial of Tubersol solution (an injectable medication used to test for tuberculosis) was not properly stored in the medication refrigerator. The findings include: Review of the facility policy titled, Storage of Medications, revised 2007, revealed the facility would store all drugs, and biological's in a safe, secure, and orderly manner. Continued review of the policy revealed the facility would not use discontinued, outdated, or deteriorated drugs or biological's. Further review revealed all such drugs were to be returned to the dispensing pharmacy or destroyed. Observation on 03/05/2025 at 9:47 AM, of the front hall medication room refrigerator, revealed one opened vial of Tubersol available for use, with an opened date of 01/30/2025. During interview with Licensed Practical Nurse (LPN) 1, on 03/05/2025 at 9:52 AM, she stated night shift…

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, record review, and review of facility policy, the facility failed to establish and maintain a proper infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases. Observation during wound care on 03/06/2025 at 9:50 AM, revealed Licensed Practical Nurse (LPN) 3 failed to clean the bedside table or place a barrier device to cover it, prior to placing the residents' clean wound dressing supplies on the table for 2 of 14 sampled residents (Resident (R)3 and R11). The findings include: Review of the facility's policy, Infection Control Policy undated, revealed the facility's objectives for its infection control policy included prevention of infection achieved through proper infection control procedures. Per review, the proper infection control procedures included, but were not limited to, handwashing; use of Personal Protective Equipment (PPE); isolation practices,…

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.