Brighton Place West

In the surveyor’s words

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

• Immediate jeopardy, isolatedF740Aug 28, 2025

  The facility identified a census of 50 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral care and services for Resident (R) 1, who had moderate cognitive impairment as well as schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of violence and substance abuse. On 07/07/25, R1 began refusing to take his mental health medications and demonstrated increased behaviors. […]

• Immediate jeopardy, isolatedF689Oct 20, 2021

  The facility identified a census of 41 residents. The sample included four residents identified at risk for elopement (when a resident with poor safety awareness, leaves the facility without staff knowledge). Based on record review, observation, and interview the facility failed to provide adequate supervision and appropriate interventions to prevent an elopement. Resident (R1), who ambulated independently and was identified at high risk for elopement, was not checked for approximately 3.5 hours and during that time, exited the facility (between 04:30 A.M. and 08:05 AM) on 10/18/21. A day long search was unable to locate the resident. […]

• Actual harm, isolatedF760Oct 17, 2024

  The facility identified a census of 48 residents. The sample included 13 residents with five residents reviewed for significant medication errors. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 21 remained free of significant medication errors. On 12/28/24 the facility received an order from R21's psychiatric provider to discontinue Clozaril (an antipsychotic medication used to treat major mental conditions that cause a break from reality) 25 milligrams (mg) in the morning. Licensed Nurse (LN) G discontinued both the 25 mg dose of Clozaril scheduled in the morning and the 500 mg dose of Clozaril at bedtime creating an abrupt discontinuation of the medication. […]

• No harm, potential for more than minimal, widespreadF812Oct 17, 2024

  The facility had a census of 48 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 48 residents in the facility, who received their meals from the kitchen. This placed the residents at risk of foodborne illness. Findings included: - On 10/14/24 at 8:00 AM, during the initial tour, observations revealed the following: The refrigerator had an opened, undated half-full 2.5 pounds container of deli turkey meat, an undated peanut butter sandwich, and two plastic bags of shredded lettuce dated 09/29/24 (15 days). Observation revealed five 12-inch by three-foot fluorescent lights located above the food preparation area. […]

• No harm, potential for more than minimal, widespreadF725May 15, 2023

  The facility identified a census of 49 residents. The sample included 13 residents. Based on record review and interviews, the facility failed to ensure sufficient Licensed Nurse (LN) coverage and adequate weekend staffing. This placed the facility residents at risk for a decline and inadequate resident cares being completed. Findings included: - A review of the Facility assessment dated [DATE] indicated the facility should have a one LN, one Certified Medication Aide (CMA), and three Certified Nurse's Aides (CNA) for morning (06:00AM to 02:00PM) and day (02:00PM to 10:00PM) shifts. The assessment indicated the facility needed one LN and two CNAs for night shift (10:00PM to 06:00AM). […]