A list of the most recent deficiencies for Brighton Place North. 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? |
|---|---|---|---|---|
| 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 | 2022-11-01 | 2022-12-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-01 | 2022-12-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-01 | 2022-12-02 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-11-01 | 2022-12-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-01 | 2022-12-02 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-11-01 | 2022-12-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-20 | 2022-11-26 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-10-20 | 2022-11-26 | Y |
| 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 | 2022-10-20 | 2022-11-26 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-10 | 2021-09-10 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-08-10 | 2021-09-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-08-10 | 2021-09-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-10 | 2021-09-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-10 | 2021-09-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-10 | 2021-09-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-08-10 | 2021-09-10 | 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 | 2021-07-07 | 2021-08-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-07 | 2021-08-18 | 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 | 2021-07-07 | 2021-08-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-07 | 2021-08-18 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-07-07 | 2021-08-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-07 | 2021-08-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-07 | 2021-08-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-18 | 2019-12-20 | 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 | 2019-11-18 | 2019-12-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-18 | 2019-12-20 | 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 | 2019-11-18 | 2019-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-18 | 2019-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-18 | 2019-12-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-18 | 2019-12-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-28 | 2019-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-28 | 2019-11-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-28 | 2019-11-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-28 | 2019-11-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-28 | 2019-11-08 | N |
