A list of the most recent deficiencies for Brighton Place West. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-15 | 2023-06-27 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-05-15 | 2023-06-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-15 | 2023-06-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-15 | 2023-06-27 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-15 | 2023-06-27 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-05-15 | 2023-06-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-15 | 2023-06-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-15 | 2023-06-27 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-15 | 2023-06-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-15 | 2023-06-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-15 | 2023-06-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-15 | 2023-06-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Use approved construction type or materials. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-23 | 2023-06-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-23 | 2023-05-24 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-05-23 | 2023-05-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-13 | 2022-01-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-13 | 2022-01-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-13 | 2022-01-28 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-13 | 2022-01-21 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-12-13 | 2022-01-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-12-13 | 2022-01-10 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-12-13 | 2021-12-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-12-13 | 2021-12-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-12-13 | 2021-12-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-12-13 | 2021-12-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-13 | 2021-12-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-13 | 2021-12-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-12-13 | 2021-12-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-12-13 | 2021-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-13 | 2021-12-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-01 | 2021-12-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-12-01 | 2021-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-01 | 2021-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-20 | 2021-10-20 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-12-31 | 2020-01-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-31 | 2020-01-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-12-31 | 2020-01-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-31 | 2020-01-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-12-31 | 2020-01-24 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-06 | 2019-12-11 | N |
