Brightmoor Nursing Center, LLC

In the surveyor’s words

From the most serious findings on record at Brightmoor Nursing Center, LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 21, 2025

  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… […]

• No harm, potential for more than minimal, widespreadF812Oct 28, 2021

  Based on observation, policy review and staff interviews, the facility failed to ensure frozen food items in the walk-in freezer were properly labeled, dated, and discarded. In addition, the facility failed to maintain the cleanliness of the main ice machine located in the kitchen. This deficient practice had the potential to effect 107 residents receiving an oral diet. Findings include: 1. During the initial tour observation and interview on 10/26/21 at 9:00 a.m. with the Dietary Director (DD) revealed the following items were located in the freezer without proper labeling to include a date indicating when the item was received, when the item was opened, the expiration date, and/or the use-by date: One large, clear, plastic bag of Beef Ravioli with a hand-written date of 2/23/21 and no… […]

• No harm, potential for more than minimal, isolatedF600Mar 18, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF552Dec 21, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF554Dec 21, 2025

  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. […]