Brighton Bay Center for Rehabilitation and Healing

In the surveyor’s words

From the most serious findings on record at Brighton Bay Center for Rehabilitation and Healing, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF755Aug 24, 2023

  Based on observations, interviews, and policy review the facility failed to ensure a system was being utilized to accurately account for all controlled substances (narcotics) related to Controlled Drugs Shift Audits not being completed on five out of five medication carts in the facility. Findings included: On 8/24/23 the Controlled Drugs Shift Audits on the 2 [NAME] medication cart were observed to be incomplete. The July 2023 Controlled Drugs Shift Audit form showed 44 out of 62 possible shifts were not signed properly by two nurses when counting narcotics at shift change. The August 2023 Controlled Drugs Audit form showed 36 out of 48 possible shifts were not signed properly by two nurses when counting narcotics at shift change. […]

• No harm, potential for more than minimal, patternF684Jun 16, 2025

  Based on observation, interview and record review, the facility failed to ensure surgical wounds were assessed and measured for three residents (#2, #6, #7) out of three sampled residents. Findings included: 1. Review of the admission Record showed Resident #2 was admitted on [DATE] with diagnoses included but not limited to rhabdomyolysis, open wound right hip, paroxysmal atrial fibrillation, congestive heart failure, hypertension, anemia, dementia, chronic kidney disease, generalized muscle weakness, history of falls, intervertebral disc degeneration, lumbar region with discogenic back pain only. Review of the admission, Minimum Data Set (MDS) dated [DATE] showed in Section C, Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). […]

• No harm, potential for more than minimal, patternF584Mar 27, 2025

  Based on observations, interviews, and review of facility policy, the facility failed to ensure a safe and homelike environment was provided in 13 resident rooms (#201, #203, #118, #114, #108, #107, #110, #112, #259, #253, #138, #137, and #146) of 74 resident rooms in the facility. Findings included: 1. During an observation made on 3/24/2025 at 9:14 a.m., room [ROOM NUMBER] was observed with a hole in the wall behind the room door. During an observation made on 3/24/2025 at 9:30 a.m., room [ROOM NUMBER] was observed with a loose toilet seat attached to the resident's bathroom toilet. 20536 2. During facility tours on 3/24/2025 at 9:40 a.m., 3/25/2025 at 8:10 a.m., and on 3/26/2025 at 7:45 a.m. and 9:00 a.m., the following was observed: a. […]

• No harm, potential for more than minimal, patternF645Mar 27, 2025

  Based on interview and record reviews, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were accurate and updated to include current diagnoses for three residents (#29, #28, #77) out of 28 sampled residents. Findings included: 1. Review of Resident #29's Admission Record showed Resident #29 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia (added 12/23/20), anxiety (added 4/20/20), and major depressive disorder. Review of the Level I PASRR, dated 7/16/20 showed in Section I: PASRR Screen Decision-Making, A. MI (Mental Illness) or suspected MI (check all that apply), no MI or suspected MI was selected. During an interview on 3/25/25 at 3:28 p.m. […]

• No harm, potential for more than minimal, patternF880Mar 27, 2025

  Based on observations, record reviews, and interviews, the facility failed to 1. Implement an effective infection control program related to the use of Personal Protective Equipment (PPE) in one resident (#162) room of four transmission-based precaution rooms; 2. Failed to store or dispose an indwelling catheter bag when not used for one resident (#78) of six sampled residents who utilized catheters; and 3. Failed to ensure staff completed appropriate hand hygiene during one of three meal observations, (3/24/2025) and during care for one resident (#38) of 42 sampled residents, and 4. […]