Pennsylvania Department of Health
BRIGHTON REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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BRIGHTON REHABILITATION AND WELLNESS CENTER
Inspection Results For:

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BRIGHTON REHABILITATION AND WELLNESS CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated survey in response to six complaints completed on July 24, 2024, it was determined that Brighton Rehabilitation and Wellness Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

�483.10(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

�483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

�483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

�483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Plan of Correction - To be completed: 08/08/2024

1. Medication regimen was reviewed with resident representative by the unit manager on 7/23/2024.

2. A house audit will be done by director of nursing/designee of residents on antipsychotics to ensure there is evidence of discussion with resident/representative on risk, benefits and possible side effects.

3. Director of nursing/designee will educate licensed staff on reviewing risks, benefits, and possible side effects of antipsychotic medications when receiving new orders, as well as reviewing new orders with resident or their representative.

4. Director of nursing/designee will audit 5 residents receiving antipsychotics weekly x 2 weeks, 3 residents receiving antipsychotics x 2 weeks, then 5 residents receiving antipsychotics x 2 months to ensure evidence of discussion on antipsychotic usage including risks, benefits and possible side effects is documented.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

�483.21(b) Comprehensive Care Plans
�483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at �483.10(c)(2) and �483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under �483.24, �483.25 or �483.40; and
(ii) Any services that would otherwise be required under �483.24, �483.25 or �483.40 but are not provided due to the resident's exercise of rights under �483.10, including the right to refuse treatment under �483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
�483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on review of facility documentation, interview with staff, it was determined that the facility failed to develop a comprehensive care plan to meet residents needs for one of four residents reviewed (Resident R3).

Findings include:

Review of Resident Assessment Instrument 3.0 User Manual effective October 2023, indicated that a Brief Interview Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15 cognitively intact
8-12 moderately impairment
0-7 severe impairment

Review of Resident R2 Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 5/2/24, included diagnosis of dementia (impairment of brain function). Review of Section C. Cognitive Patterns, Questions C0500"BIMS Summary Score" revealed Resident R2 score to be 3.

Review of Resident R3 Admission record indicated he was admitted to the facility on 1/11/24.

Review of Resident R3 MDS dated 5/8/24, included diagnosis of Traumatic Brain Injury (acquired brain injury). Review of Section C. Cognitive Patterns, Questions C0500 "BIMS Summary Score" revealed Resident 3 score to be a 12.

Review of facility documentation submitted on 7/12/24, indicated the following: "Resident R2 had her breast fondled by Resident R3: On 07/12/24, while Employee E was rounding Resident R2 was found laying in Resident R3's bed topless as Resident R3 was fondling her breasts. At time of incident neither resident was noted not to be in any emotional distress. Residents immediately separated and Resident R2 was removed from Resident R3 room. Resident R3 believed that Resident R2 was his ex-wife."

During interviews on 7/23/24, between 11:50 am. And 12:10 pm Facility staff indicated that Resident R3 had behaviors and believed that Resident R3, was his ex - wife. He would address Resident R2 as his ex-wife by ex-wife's name, they would sit together and staff would have to re-direct Resident R3 that this was not his ex-wife. Staff also stated the Resident R2 Follows staff and residents around unit.

Review of Resident R3 clinical record care plans failed to include a care plan for Resident R3 behavior of thinking Resident R2 was his ex-wife, calling Resident R2 his ex-wife's name or any monitoring to ensure that the behaviors did not escalate.

During an interview on 7/23/24, at 4:30 p.m. Director of Nursing confirmed that the facility failed to develop a comprehensive care plan to meet Resident R3 behavior of thinking Resident R2 was his ex-wife and failed to provide monitoring to ensure behaviors did not escalate.

28 Pa. Code211.11(d)Resident care plan.

Plan of Correction - To be completed: 08/08/2024

1. Resident R3 was moved to a different unit away from resident R2. Care plans were revised.

2. Director of nursing/designee will conduct house review of resident documentation for the past 30 days will be done to assess for behaviors not reflected in residents' current care plan.

3. Nursing staff will be educated by director of nursing/designee on reporting resident behaviors to nursing to ensure care plan appropriately reflects residents' needs.

4. Director of nursing/designee will audit nursing documentation 3 times weekly for 2 weeks, weekly for 2 weeks, then 3 times monthly for 2 months to ensure resident behavior appropriately care planned.

483.40 REQUIREMENT Behavioral Health Services:

�483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.

Observations:

Based on review of clinical record, staff interviews it was determined that the facility failed to provide behavioral services for a behavioral need for one of four residents reviewed (Resident R3).

Findings include:

Review of Resident Assessment Instrument 3.0 User Manual effective October 2023, indicated that a Brief Interview Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15 cognitively intact
8-12 moderately impairment
0-7 severe impairment

Review of Resident R3 Admission record indicated he was admitted to the facility on 1/11/24.

Review of Resident R3 MDS dated 5/8/24, included diagnosis of Traumatic Brain Injury (acquired brain injury). Review of Section C. Cognitive Patterns, Questions C0500 "BIMS Summary Score" revealed Resident 3 score to be a 12.

Review of facility documentation submitted on 7/12/24, indicated the following: "Resident R2 had her breast fondled by Resident R3: On 07/12/2024 while Employee E6 was rounding Resident R2 was found laying in Resident R3's bed topless as Resident R3 was fondling her breasts. At time of incident neither resident was noted not to be in any emotional distress. Residents immediately separated and Resident R2 was removed from Resident R3 room. Resident R3 believed that Resident R2 was his ex-wife."

During interviews on 7/23/24, between 11:50 am. And 12:10 pm Facility staff indicated that Resident R3 had behaviors and believed that Resident R3, was his ex - wife. He would address Resident R2 as his ex-wife by ex-wife's name, they would sit together and staff would have to re-direct Resident R3 that this was not his ex-wife. Staff also stated the Resident R2 Follows staff and residents around unit.

During an interview on 7/23/24, at 4:10 p.m. Resident R3 did indicated he did not understand why he had to change floors for being with his ex-wife.

During an interview on 7/23/24, at 4:30 p.m. Director of Nursing confirmed that the facility staff were aware of Resident R3's behavior and did not implement services to meet his needs and failed to provide behavioral services for Resident R3.

28 Pa. Code 201.14(a)Responsibility of licensee.

Plan of Correction - To be completed: 08/08/2024

1. R2 and R3 care plans were updated to reflect their behavioral needs. Incident was reported via ERS system reference ID #1019407.

2. An audit will be done by director of nursing/designee of residents requiring behavioral health services to ensure care plan is appropriate and psych services are in place as needed.

3. Director of nursing/designee will educate nursing staff on communicating resident behaviors to licensed nurses so they may be care planned and addressed appropriately.

4. Director of nursing/designee will audit behavior care plans of 3 residents weekly for 2 weeks, 2 residents weekly for 2 weeks, then 2 residents monthly for 2 months to ensure behavioral needs are addressed. New behaviors will be reviewed in clinical meeting on an ongoing basis to ensure care planning is appropriate.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:

�483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Observations:

Based on facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide necessary services and failed to make certain appropriate treatment and services for dementia were provided to one of four residents (Resident R2).

Findings include:

Review of facility policy "Guidelines for Caregiver Interaction with Dementia" dated 10/1/23, indicated: "Guideline Statement: To ensure that Caregivers understand how to interact with residents living with Dementia and/or Cognitive Deficits. Staff will interact with residents in a manner that supports dignity and enhances residents abilities to successfully participate in life."

Review of Resident Assessment Instrument 3.0 User Manual effective October 2023, indicated that a Brief Interview Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15 cognitively intact
8-12 moderately impairment
0-7 severe impairment

Review of Resident R2 admission record indicated she was admitted to the facility on 12/27/18.

Review of Resident R2 Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 5/2/24, included diagnosis of dementia (impairment of brain function). Review of Section C. Cognitive Patterns, Questions C0500"BIMS Summary Score" revealed Resident R2 score to be 3.

Review of Resident R3 Admission record indicated he was admitted to the facility on 1/11/24.

Review of Resident R3 MDS dated 5/8/24, included diagnosis of Traumatic Brain Injury (acquired brain injury). Review of Section C. Cognitive Patterns, Questions C0500 "BIMS Summary Score" revealed Resident 3 score to be a 12.

Review of facility documentation submitted ON 7/12/24, indicated the following: "
Resident R2 had her breast fondled by Resident R3: On 7/12/24 while Employee E6 was rounding Resident R2 was found laying in Resident R3's bed topless as Resident R3 was fondling her breasts. At time of incident neither resident was noted not to be in any emotional distress. Residents immediately separated and Resident R2 was removed from Resident R3 room. Resident R3 believed that Resident R2 was his ex-wife.

During interviews on 7/23/24, between 11:50 am. and 12:10 pm Facility staff indicated that Resident R3 had behaviors and believed that Resident R3, was his ex - wife. He would address Resident R2 as his ex-wife by ex-wife's name, they would sit together and staff would have to re-direct Resident R3 that this was not his ex-wife. Staff also stated the Resident R2 Follows staff and residents around unit.

Review of Resident R3 clinical record failed to include documentation of Resident R3 behaviors towards Resident R2.

During an interview on 7/23/24, at 4:30 p.m. Director of Nursing confirmed that the facility failed to identify behaviors and failed to protect Resident R2 from Resident R3 behavior, and failed to make certain appropriate treatment and services for dementia were provided to one of four residents (Resident R2).

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
28 Pa. Code 201.29 (a)(b)(c)(i)(n) Resident rights

Plan of Correction - To be completed: 08/08/2024

1. Residents R2 and R3 care plans were updated to reflect their behavioral needs. R3 is receiving dementia services and sees psychiatry for conjunctive medication management. Incident was reported via ERS system reference ID 1019407. Resident R2 was moved to a different unit.
2. An audit will be done by director of nursing/designee of residents requiring behavioral health services to ensure care plan is appropriate and psych services are in place as needed.

3. Director of nursing/designee will educate nursing staff on communicating and documenting resident behaviors so they may be care planned and addressed appropriately.

4. Director of nursing/designee will audit behavior care plans of 3 residents weekly for 2 weeks, 2 residents weekly for 2 weeks, then 2 residents monthly for 2 months to ensure behavioral needs are addressed. 24 hour report will be reviewed daily in clinical meeting on an ongoing basis to ensure any new or worsening behavioral needs are addressed.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program:

�483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Observations:

Based on review of facility policy, pest control service invoices, pest sighting logs, observations, and staff interviews it was determined that the facility failed to maintain an effective pest control program for one out of five observed resident kitchenettes (2-East kitchenette).

Findings include:

The facility "Pest control program" policy dated 10/1/23, indicated that the resident has the right to a clean and homelike environment. The facility shall have processes in place to include a pest control program as identified by a contracted vended service. The facility will maintain an effective pest control program.

Review of records of invoices from pest service provider dated July 2024, indicated that mouse traps were laid out; however, the record did not include evidence of efforts to eradicate mice on the 2-East nursing unit in July 2024.

Review of Pest sighting log for May 2024, June 2024 and July 2024, indicated that rats and mice were observed in the nursing home on 5/21/24, 5/28/24, 6/10/24, 6/17/24, 6/24/24, and 7/4/24.

During observations on 7/23/24, the 2-East Resident Kitchenette was observed with the following:
At 10:14 a.m. observations with Licensed Practical Nurse (LPN) Supervisor Employee E2 of the lower cabinet under the sink found a box with peanut butter cup snacks for residents. Observations of three peanut butter cups ripped open. The large brown box was observed surrounded by small mice droppings.

During an interview on 7/23/24, at 10:15 a.m. Licensed Practical Nurse (LPN) Supervisor Employee E2 stated: "I did not know that was there. This needs cleaned up."

During an interview on 7/23/24, at 10:27 a.m. 2-East resident kitchenette observed with Maintenance Supervisor Employee E3. Maintenance Supervisor Employee E3 stated the following: "The Housekeeping supervisor keeps logs and calls pests control. There are no work orders for rodents for this floor. I do see mice droppings. All the food will have to be thrown away."

During an interview on 7/23/24, at 10:29 a.m. Maintenance Supervisor Employee E3 confirmed that the facility failed to maintain an effective pest control program for the resident 2-East Kitchenette as required.

28 Pa. Code 201.18(e)(2) Management
28 Pa Code 207.20 (a) Administrator's responsibility

Plan of Correction - To be completed: 08/08/2024

1. Area under sink on E2 was cleaned and sealed. Pest control was notified to inspect this area on their next visit. The pest control vendor is on site regularly twice per month and on average 15 times per month for other ancillary requests, pest control requests/maintenance. The pest control vendor was onsite 7/25, 7/29, 8/5 and ongoing as needed.

2. All kitchenettes were audited to be clean and orderly and without indication of pests.

3. All unit directors and administrative team members were re inservice by the Administrator to ensure they follow the existing policy and procedure for notifying the director of housekeeping in the event the pest control vendor needs to appear on site.

4. The director of environmental services or designee will audit Kitchenettes on units weekly for 4 weeks to ensure clean and orderly without indication of pests.

� 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of facility policy, nursing staffing documents and staff interview, it was determined that the facility failed to provide the State required minimum of one Nurse Aide (NA) per 10 residents on the daylight shifts for four out of 21 days (7/6/24, 7/7/24, 7/14/24, and 7/21/24) and failed to provide the State required minimum of one NA per 11 residents on seven out of 21 evening shifts (7/5/24, 7/6/24, 7/7/24, 7/14/24, 7/17/24, 7/18/24, and 7/19/24).

Findings include:

The facility "Nursing department staff" policy last reviewed 10/1/23, indicated that the facility will provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: licensed nurses and other nursing personnel.

A review of 3-week nurse staffing schedules (7/3/24-7/23/24) did not include the State required minimum of Nurse Aides (NA) on the daylight shifts for the following days: (7/6/24, 7/7/24, 7/14/24, and 7/21/24)

A review of 3-week nurse staffing schedules (7/3/24-7/23/24) did not include the State required minimum of Nurse Aides (NA) on the evening shifts for the following days: (7/5/24, 7/6/24, 7/7/24, 7/14/24, 7/17/24, 7/18/24, and 7/19/24).

During an interview on 7/24/24, at 1:02 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide the State required minimum of one Nurse Aide (NA) per 10 residents on the daylight shifts on 7/6/24, 7/7/24, 7/14/24, and 7/21/24 and failed to provide the State required minimum of one Nurse aide (NA) per 11 residents for evening shifts on 7/5/24, 7/6/24, 7/7/24, 7/14/24, 7/17/24, 7/18/24, and 7/19/24 as required.

Plan of Correction - To be completed: 08/08/2024

1. The NHA reviewed the staffing structure, ratios, and PPD's in accordance with the newly implemented state regulation. The facility continues to to deploy clinical agency staff with optimized call off systems that automatically open their shift to all members in the event staff members call off.

2. The licensed Administrator re-in serviced the schedulers on the policy, procedure, and regulation in order to ensure the staffing ratio is met.

3. The licensed Administrator reviews staffing daily.

4. The licensed Administrator or designee will report findings to QAPI.

� 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of facility policy, nursing time schedule documents, and staff interview, it was determined that the facility to provide a minimum of one licensed practical nurse (LPN) per 25 residents during daylight shifts for three out of 21 days (7/6/24, 7/7/24, and 7/21/24) and failed to provide a minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift for two out of 21 days (7/6/24 and 7/19/24).

Findings include:

The facility "Nursing department staff" policy last reviewed 10/1/23, indicated that the facility will provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: licensed nurses and other nursing personnel.

A review of 3-week nurse staffing schedules (7/3/24-7/23/24) did not include one Licensed Practical Nurse (LPN) per 25 residents during the day shift on the following dates: 7/6/24, 7/7/24, and 7/21/24.

A review of 3-week nurse staffing schedules (7/3/24-7/23/24) did not include one Licensed Practical Nurse (LPN) per 30 residents during the evening shift on the following dates: 7/6/24 and 7/19/24.

During an interview on 7/24/24, at 1:02 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during daylight shifts for 7/6/24, 7/7/24, and 7/21/24 and failed to provide a minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shifts for 7/6/24 and 7/19/24 as required.

Plan of Correction - To be completed: 08/08/2024

1. The NHA reviewed the staffing structure, ratios, and PPD's in accordance with the newly implemented state regulation. The facility continues to deploy clinical agency staff with optimized call off systems that automatically open their shift to all members in the event staff members call off.

2. The licensed Administrator re-in serviced the schedulers on the policy, procedure, and regulation in order to ensure the staffing ratio is met.

3. The licensed Administrator reviews staffing daily.

4. The licensed Administrator or designee will report findings to QAPI.

� 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of facility policy, nursing time schedules and staff interview it was determined that the facility failed to provide a minimum of 3.20 PPD (per patient daily) hours of direct care for each resident for eight out of 21 days reviewed (7/5/24, 7/6/24, 7/7/24, 7/14/24, 7/17/24, 7/18/24, 7/20/24, and 7/21/24. ).

Findings include:

The facility "Nursing department staff" policy last reviewed 10/1/23, indicated that the facility will provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: licensed nurses and other nursing personnel.

Review of staffing documents and nurse schedules for 3 weeks (7/3/24-7/23/24) indicated that State required PPD (per patient daily) minimum hours of 3.20 was not met on the following days:
7/5/24= 3.00 PPD
7/6/24= 2.54 PPD
7/7/24= 2.63 PPD
7/14/24= 2.98 PPD
7/17/24= 3.18 PPD
7/18/24= 3.15 PPD
7/20/24= 3.15 PPD
7/21/24= 2.89 PPD

During an interview on 7/24/24, at 1:02 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of 3.20 PPD hours of direct care on 7/5/24, 7/6/24, 7/7/24, 7/14/24, 7/17/24, 7/18/24, 7/20/24, and 7/21/24 as required.

Plan of Correction - To be completed: 08/08/2024

1. The NHA reviewed the staffing structure, ratios, and PPD's in accordance with the newly implemented state regulation. The facility continues to to deploy clinical agency staff with optimized call off systems that automatically open their shift to all members in the event staff members call off.

2. The licensed Administrator re-in serviced the schedulers on the policy, procedure, and regulation in order to ensure the Nursing department PPD is met.

3. The licensed Administrator reviews staffing daily.

4. The licensed Administrator or designee will report findings to QAPI.

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