Sarah S Brayton Center

In the surveyor’s words

From the most serious findings on record at Sarah S Brayton Center, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 18, 2023

  Based on observation, record review, and staff interview, the facility failed to provide adequate supervision and accident prevention interventions to maintain the safety of one Resident (#76), out of a total sample of 32 residents. Specifically, the facility failed to provide adequate supervision to maintain the Resident's safety and prevent falls, and/or injury, resulting in Resident #76 sustaining a total of 14 falls from the time of their admission (January 2023) to 8/27/23; 12 of which were unwitnessed, and one resulted in the Resident being transported to the emergency room for a head laceration that required three staples. […]

• Actual harm, isolatedF686Mar 18, 2021

  Based on observation, interview, and record review, the staff failed to ensure that Residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing for one Resident (#35) out of 26 sampled Residents. Specifically, the facility failed to ensure nursing assessed and measured pressure wounds per facility policy, failed to provide pressure relieving devices as recommended and per facility policy, failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. […]

• No harm, potential for more than minimal, patternF565Feb 20, 2026

  Based on review of Resident Council Minutes, a resident group meeting, interviews, and record reviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.Findings include:Review of the facility's policy titled Resident Council, dated 2001, indicated but was not limited to the following:-The purpose of the Resident Council is to provide a forum for: a. Residents to have input in the operation of the facility; b. Discussion of concerns and suggestions for improvement; c. Consensus building and communication between residents and facility staff; and d. […]

• No harm, potential for more than minimal, patternF658Feb 20, 2026

  Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for five Residents (#81, #108, #12, #136 and #132), out of a total sample of 33 residents. Specifically, the facility failed:1. For Residents #81 and #108, to implement physician's orders for air mattress settings;2. For Residents #12 and #136, to implement physician's orders for oxygen; and 3. For Resident #132, to ensure physician's orders were in place upon admission for a continuous positive airway pressure (CPAP) machine (uses air pressure to hold the airway open while sleeping). […]

• No harm, potential for more than minimal, patternF692Feb 20, 2026

  Based on observations, interviews, and record review, the facility failed to implement nutritional interventions to maintain acceptable parameters of nutritional status for two Residents (#12, #50), with unplanned gradual weight loss, and one Resident with significant weight gain (#95), in a total sample of 33 residents. Specifically, the facility failed:1. For Resident #12, to identify and develop interventions to prevent and address a 12.4% significant weight loss between 8/1/25 and 2/2/26;2. For Resident #50, to identify and develop interventions to prevent and address a 17.57% significant weight loss between 11/4/25 and 2/12/26; and3. […]