Brighton Care Center

In the surveyor’s words

From the most serious findings on record at Brighton Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 26, 2025

  Based on interview and record review, the facility failed to ensure two of two sampled residents (Residents 1 and 2) were free from falls and injury by failing to: 1.a Ensure Certified Nursing Assistant 2 (CNA 2) did not leave Resident 1 who was assessed to require increased assistance to perform tasks and the resident would benefit from caregiver (facility staff) supervision to decrease fall risk, without facility staff to supervise Resident 1 in the resident's room while the resident is sitting in a wheelchair during breakfast on 3/11/2025 in accordance with Resident 1's Physical Therapy (PT - healthcare profession that focuses on promoting, maintaining, or restoring health through patient education, physical intervention, disease prevention, and health promotion) Recertification (PTR -… […]

• No harm, potential for more than minimal, patternF695Jan 29, 2026

  Based on observation, interview and record review, the facility failed to provide the necessary respiratory care services for two (2) of three (3) sampled Residents ( Residents 102 and 13) reviewed for oxygen (O2, a highly reactive, colorless, odorless gas vital for life) as indicated in the facility policy by failing to:Provide Resident 102 a new humidifier (a device used to add moisture to dry oxygen, reducing irritation in the nose and throat for residents during oxygen therapy) when it was empty on 1/26/2026.Administer Resident 13's oxygen as indicated on the physician's order.These deficient practices have the potential for Residents 102 and 13 to develop respiratory complications associated with oxygen therapy.Findings: 1. […]

• No harm, potential for more than minimal, patternF755Jan 29, 2026

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for six (6) of 10 sampled residents (Residents 95, 64, 24, 82, 15, and 109) reviewed and observed for medications administration, in accordance with the facility's policy and procedure (P&P) by failing to: 1.Administer metformin (medication used to control high blood sugar levels) and potassium chloride (medication used to regulate the heartbeat) within 60 minutes of the scheduled time of 7:15 AM for Resident 95.This deficient practice had the potential for Resident 95 to experience chest pain, shortness of breath, dizziness, and placed Resident 95 at risk for inadequate… […]

• No harm, potential for more than minimal, patternF759Jan 29, 2026

  Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Eight (8) medication errors (the observed or identified preparation or administration of medication or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 29 opportunities (observed administered medications) for error which yielded a facility medication error rate of 27.59% for four (4) of 10 sampled residents (Residents 95, 64, 24, and 82) observed for medication administration (med pass).Licensed Vocational Nurse 1 (LVN 1) failed to administer metformin (medication used to control high blood sugar levels) and potassium chloride (medication used to… […]

• No harm, potential for more than minimal, patternF760Jan 29, 2026

  Based on observation, interview, and record review, the facility failed to ensure four (4) of 10 sampled residents (Resident 95, 64, 24, and 82) were free from significant medication errors by facility to:1.Administer metformin (medication used to control high blood sugar levels) and potassium chloride (medication used to regulate the heartbeat) within 60 minutes of the scheduled time of 7:15 AM for Resident 95.This deficient practice had the potential for Resident 95 to experience chest pain, shortness of breath, dizziness, and placed Resident 95 at risk for inadequate blood sugar management which could cause hyperglycemia (elevated blood sugar level). 2. […]