Spaulding Nursing and Therapy Center - Brighton

In the surveyor’s words

From the most serious findings on record at Spaulding Nursing and Therapy Center - Brighton, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 19, 2022

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure he/she was provided adequate supervision to maintain his/her safety to prevent an incident/accident resulting in an injury. On 11/27/22 during the overnight shift, the nurse applied a hot pack to Resident #1's abdominal area, however, the nurse did not follow hot pack instructions when she applied it to Resident #1, and Resident #1 was left unattended with the hot pack in place. When the nurse returned to remove the hot pack, Resident #1 was found to have a second degree burn (burn that affects both the outer and underlying layer of skin, they cause pain, redness, swelling and blistering) to the mid- lower quadrant of his/her abdomen. . […]

• No harm, potential for more than minimal, widespreadF880Jan 27, 2021

  Based on observations, interview and facility policy review, the facility failed to implement infection control procedures to reduce the possible transmission of communicable diseases including COVID-19 by failing to (1.) perform hand hygiene when indicated on three of three patient units (2.) remove gloves and perform hand hygiene prior to exiting a patient room and (3.) keep soiled items off of the floor in communal corridors. Findings include: The facility policy titled Hand Hygiene, reviewed 11/15/21, indicated: * Perform hand hygiene before and after contact with equipment or other items in the patient's room. * Perform hand hygiene before and after using gloves. […]

• No harm, potential for more than minimal, patternF761Mar 12, 2025

  Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biological's in accordance with State and Federal requirements. Specifically, the facility failed to ensure medication carts were locked while a nurse was not present. Findings include: Review of the facility policy titled Medication Storage, dated revised 8/2/24, indicated that carts, cabinets and other areas containing medications must be kept locked at all times when not in use. Further review indicated that all medications on the nursing units are stored securely in the med (medication) carts. On 3/11/25 at 7:42 A.M., the surveyor observed a medication cart unlocked and unattended in the hallway of the 2nd floor nursing unit. […]

• No harm, potential for more than minimal, isolatedF554Mar 12, 2025

  Based on observation, interview and policy review, the facility failed to ensure a resident was assessed for the ability to self-administer medications, failed to observe a resident take prescribed medication, and left the medication at the bedside, unsecured. Findings include: Review of the facility policy Medication Administration dated 5/28/24, indicated: - Observe the patient taking the medication and no medications are left at bedside. On 3/11/25 at 8:46 A.M., the surveyor observed a resident in his/her room sitting in a chair located in front of a breakfast tray. On the tray was a medicine cup which contained 8 pills of various sizes and colors. The Resident said that about five minutes ago a nurse left the medicine on his/her breakfast tray and then left the room. […]

• No harm, potential for more than minimal, isolatedF686Mar 12, 2025

  Based on observation, record review and interview the facility failed to implement a treatment order timely for an identified pressure injury for one Resident (#184), out of a total sample of 20 residents. Specifically, for Resident #184, a treatment order was not implemented until 72 hours after the facility first identified his/her pressure injury. Findings include: Review of the facility's Skin and Wound Care Policy, with a current revision date 3/4/2025 includes but is not limited to the following: Purpose: to outline how skin assessment and wound care is delivered safely and effectively within the facility. Policy Statement *Two nurses will provide a comprehensive skin assessment for all patients on admission ('four eyes skin check). […]