Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brighton Post Acute Care during CMS and state inspections, most recent first.
Physician and NP visit schedules were not followed for three residents. One resident with HF, asthma, and respiratory failure missed a required monthly visit, and two other residents with significant neurologic or cardiac conditions also had physician visits that did not alternate with NP visits as expected. The Medical Director said he typically sees residents every four months, while the DON stated the expectation was alternating MD/NP visits every 30 days for acute patients and every 60 days for long-term residents.
A facility failed to keep complete EHR records for two residents because MD and NP progress notes were not entered in a timely manner, with late entries added only after surveyor request. The facility also inaccurately documented lidocaine patch administration for one resident after knee surgery and documented oxygen concentrator filter care for another resident even though the filter was observed covered in dust. The DON, Medical Director, and nursing staff acknowledged the documentation problems.
Call Light Not Usable for A Resident: A resident with a hx of stroke and cognitive communication disorder, who was documented as cognitively intact and dependent on staff for all ADLs, did not have a usable call light. Surveyors observed the red call bell string tied to the upper corner of the bedrail so the resident could not pull it down fully to activate the system, and the resident stated the call light did not work for him/her. A CNA said the resident does not use a call light and staff check regularly, while an RN stated the call light should not be tied that way and should be closer to the resident.
Failure to Offer Resident Attendance at Care Plan Meetings: A resident with ESRD, major depressive disorder, and supplemental O2 dependence was severely cognitively impaired but still able to discuss care issues and was his/her own decision maker. The record did not show who attended the care plan meeting, and staff could not confirm that the resident or family was ever invited or offered the chance to attend. The SW and DON gave conflicting accounts of who was responsible for sending invitations, and no attendance records were found.
Failure to Follow Ordered Fluid Restrictions: Two residents with physician-ordered fluid restrictions did not have intake and output consistently measured or documented. One resident with ESRD on dialysis and severe cognitive impairment had repeated observations of beverages at the bedside, while the MAR lacked daily I&O documentation. Another resident with HF and cognitive impairment also had multiple missing or blank I&O entries, and staff gave inconsistent accounts of whether the resident was on fluid restriction or how intake was tracked.
Failure to Supervise a Resident During Meals: A resident with aphasia, ESRD, and severe cognitive impairment was observed eating breakfast in bed without staff present during the meal on multiple occasions. The care plan and Kardex directed that the resident eat only with supervision, keep the HOB elevated, and have the mouth checked after meals, but staff interviews showed conflicting understanding of the resident’s meal supervision needs.
A resident with ESRD and another resident with COPD/asthma were observed receiving oxygen without active physician orders in the chart, even though staff said oxygen was needed and should be ordered with the correct L/min. A third resident with respiratory failure and HF had an oxygen concentrator filter covered in thick dust, despite a weekly order to clean or change the filter and related oxygen equipment.
Improper lidocaine patch administration and documentation led to inadequate pain management for a resident with knee surgery and arthritis. A resident with intact cognition was observed with two lidocaine patches on the leg, including one misdated patch and one undated patch, despite an order for one patch daily. Staff stated the patches were applied in error, the order did not specify placement, and the MAR documented patch changes that did not match what was observed.
A resident’s scheduled Tylenol was found in a medication cup on the bedside table while the resident was unsupervised, even though the resident had not been approved to self-administer medications. The resident was cognitively intact, but the chart did not show bedside self-administration authorization, and staff stated the meds had been left by the overnight nurse before the required assessment was completed.
The facility inaccurately completed MDS assessments for several residents, including a significant weight gain not recorded for a resident, and incorrect coding of communication abilities for two residents who required interpreters. Additionally, a resident was incorrectly coded as comatose despite being alert and responsive. These errors were acknowledged by facility staff.
Surveyors observed deficiencies in medication storage and labeling at the facility. On one unit, medication carts were left open and unattended, and an unlabeled medication cup was found in a cart. On another unit, an unopened Levemir Flex Pen was improperly stored outside of refrigeration. Nurses acknowledged these errors, indicating a failure to follow the facility's medication management policy.
A facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who was discharged from hospice services. The resident, with dementia and a history of Covid-19, was removed from hospice in April 2024, but the required SCSA was not conducted. Staff interviews revealed a lack of awareness about the necessity of the assessment, despite the resident's improvement and hospice revocation.
Physician and NP Visit Schedule Not Followed
Penalty
Summary
The facility failed to ensure required face-to-face physician visits were completed for three sampled residents. Resident #32, admitted with heart failure, asthma, and respiratory failure and documented as cognitively intact, was seen by the physician on 12/28/24 and 9/2/25 and by the NP multiple times between those dates, but was not seen in February 2025 as required and the physician did not alternate visits with the NP. Resident #4, admitted with aphasia and coronary artery disease and documented as severely cognitively impaired and dependent for all ADLs, was seen by the physician on 9/11/24, 9/21/24, and 9/23/25, with NP visits on 9/10/24, 9/15/24, 9/19/24, 6/4/25, and 7/27/25; the physician did not alternate visits with the NP as required. Resident #15, admitted with stroke and cognitive communication disorder and documented as cognitively intact and dependent for all ADLs, was seen by the physician on 7/12/24, 9/16/25, and 9/19/25, with NP visits on 10/3/24, 10/7/24, 10/8/24, 10/29/24, 11/11/24, 11/19/24, 1/30/25, and 6/6/25. The Medical Director stated he usually sees residents every four months and the NP visits every couple months, while the DON stated the expectation was for the physician and NP to alternate visits and complete visits every 30 days for acute patients and every 60 days for long-term residents.
Incomplete Provider Notes and Inaccurate Treatment Documentation
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for Residents #44 and #8 because physician and NP progress notes were not documented in the EHR in a timely manner. Resident #44, who had diagnoses including ESRD, acute kidney failure, dialysis dependence, shortness of breath, heart disease, hypertension, atrial fibrillation, polyneuropathy, cardiomegaly, tachycardia, and supplemental oxygen dependence, had no documented provider notes in the EHR after 2/20/25 when the surveyor reviewed the record. Staff stated there were no NP or MD notes after that date in either the EHR or hard copy record, although late-entry physician notes dated 4/8/25 and 8/12/25 were later entered into the EHR after the surveyor requested them. The Medical Director and DON stated provider notes were written in a different system and were not available to staff until uploaded into the EHR. Resident #8, who had COPD and schizophrenia and was cognitively intact, also had incomplete provider documentation in the EHR. The last NP progress note was documented on 7/24/25 and the last physician note was documented as a late entry on 4/29/25. After the surveyor requested additional records, one physician note dated 8/12/25 was entered as a late entry on 9/26/25. The Medical Director and DON acknowledged that provider progress notes were being uploaded later than expected and that staff did not have access to those notes until they appeared in the EHR. The facility also failed to accurately document medication and treatment administration for Residents #42 and #32. Resident #42, admitted after left knee surgery and with arthritis, had lidocaine patches observed on the left knee and shin, including one patch dated 9/21 and another undated, despite the MAR showing patches were removed and reapplied on 9/22 and 9/23. The resident stated the patches had not been changed since 9/21, while the Unit Manager, DON, and Regional Nurse said the patch dates and MAR entries were incorrect and that one nurse failed to perform the treatment but documented it as completed. Resident #32, who had respiratory failure and heart failure and used oxygen therapy, was observed with an oxygen concentrator filter covered in a thick layer of white dust even though the TAR indicated the filter had been changed on 9/21. A clinical nurse consultant stated it did not appear the filter had been changed or cleaned as documented.
Call Light Not Usable for Resident
Penalty
Summary
The facility failed to ensure a call light was within easy reach and usable for one resident. The resident was admitted in January 2023 with diagnoses including stroke and cognitive communication disorder, and the MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15 and dependent on staff for all ADLs. The resident’s fall care plan stated the resident was at risk for falls related to deconditioning, gait and balance problems, paralysis, poor communication/comprehension, and CVA with right-sided weakness, and included an intervention to keep the call light within reach and encourage use for assistance as needed. During interview and observation, the resident stated the call light did not function for him/her. Surveyors observed a red call bell string tied to the upper corner of the left bedrail; although the resident could reach it, the cord could not be pulled down fully to activate the call light system. The same condition was observed again the next day, and the resident again stated the call light could not be used. A CNA stated the resident does not use a call light and staff check on him/her regularly. A nurse observed the call light and stated it should not be tied in that manner and should be closer to the resident. The unit manager stated the resident previously had a tap call light in the prior room, and the clinical record showed the resident changed rooms on 3/18/25.
Failure to Offer Resident Attendance at Care Plan Meetings
Penalty
Summary
The facility failed to ensure that attending care plan meetings was offered to one resident. Resident #44 was admitted in March 2022 with diagnoses including end stage renal disease and major depressive disorder, and a diagnosis of dependence on supplemental oxygen was added to the record on 9/12/24. The MDS assessment indicated the resident was severely cognitively impaired with a Brief Interview for Mental Status score of 7 out of 15, but during multiple interviews the resident was able to discuss healthcare issues including oxygen use, dialysis attendance, and pain levels. The clinical record indicated the resident’s health care proxy was not activated, meaning the resident was his/her own decision maker, and the most recent care plan meeting was held on 6/28/25. The record failed to show who attended the care plan meeting, and there were no attendance records in either the electronic or paper chart for any care plan meetings for Resident #44. During interviews, the Social Worker stated she was not responsible for inviting residents or family members to care plan meetings and was not sure who was responsible, and she was not sure whether the resident or family had ever been offered the opportunity to attend. She later reviewed the paper record but could not locate attendance sheets, and said she was not aware the resident did not have an activated healthcare proxy. The DON stated the receptionist was responsible for sending care plan invitations to residents and families, but there had been staffing changes in reception services.
Failure to Follow Ordered Fluid Restrictions
Penalty
Summary
The facility failed to implement physician-ordered fluid restrictions for two residents. One resident had diagnoses including end stage renal disease, dependence on renal dialysis, shortness of breath, atherosclerotic heart disease, tachycardia, and dependence on supplemental oxygen, and was assessed as having severe cognitive impairment. The resident had an active order for a 1000 mL/24-hour fluid restriction with specific nursing and dietary allowances by shift, but survey observations repeatedly found cups of coffee, juice, water, and cranberry juice on the overbed table. The resident’s September 2025 MAR did not include daily intake and output documentation for each nursing shift, and the medical record did not show that intake and output was measured or documented. Staff interviews confirmed that the resident was on fluid restriction and required intake and output monitoring because of dialysis and fluid overload history. A nurse stated CNA staff track intake and output and document it in the medical record or report it to nursing, while a unit manager said the order was in place but intake and output values were not being documented and expected them to be documented to monitor fluid status. The regional clinical consultant and DON also stated that intake and output should be documented each shift as ordered. During one observation, a nurse left a cup of water with the resident and said she did not know whether the resident was on a fluid restriction. A second resident, admitted with diagnoses including sepsis, heart failure, and cognitive communication deficit, had moderate cognitive impairment and was frequently incontinent of urine. This resident had an active order for a 1500 mL/24-hour fluid restriction with nursing and dietary allowances by shift. The September 2025 MAR showed multiple missing or blank intake and output entries across several shifts, including entries marked output N/A and several blank documentation periods. Staff interviews showed inconsistent awareness of the restriction: one nurse said staff check the urinal and CNA staff report intake, but a CNA stated she did not think the resident was on a fluid restriction and said staff give the resident water, juice, and ginger ale. The unit manager was not aware CNA staff did not know about the restriction, and the DON stated intake and output should be measured and documented as ordered.
Failure to Supervise a Resident During Meals
Penalty
Summary
The facility failed to provide supervision with meals for one resident who was unable to eat independently. Resident #44 was admitted with diagnoses including aphasia, other lack of coordination, end stage renal disease, and shortness of breath, and the MDS dated 9/29/25 indicated severe cognitive impairment with a BIMS score of 7 out of 15. The resident’s care plan for aspiration risk, dated 2/28/23, directed that the resident eat only with supervision, keep the head of bed elevated during meals and for 30 minutes afterward, and have the mouth checked after meals for pocketed food and debris. The current September 2025 Kardex also directed that the resident eat only with supervision and included the same positioning and mouth-check interventions. During observations on 9/24/25, 9/25/25, and 9/26/25, the surveyor saw Resident #44 in bed eating breakfast without staff present in the room throughout the meal. On each occasion, the resident was not visible from the hallway and had food on clothing, and on two occasions food was also observed on the bed linen or floor. The nutritional assessment left dining ability blank. Staff interviews showed differing understanding of the resident’s needs: a CNA and a nurse stated the resident did not require supervision, while the Unit Manager stated the resident needed supervision during meals and that the care plan and Kardex must be followed. The DON stated residents who need supervision during meals should not be left alone while eating and said she was not aware the resident required supervision due to aspiration risks.
Oxygen Therapy Provided Without Orders and Equipment Not Properly Maintained
Penalty
Summary
The facility failed to ensure respiratory care was provided with a physician order for two residents who were receiving oxygen therapy. One resident with end stage renal disease, dependence on dialysis, shortness of breath, heart disease, tachycardia, and dependence on supplemental oxygen was observed multiple times receiving oxygen by nasal cannula at 2 to 2.5 liters, but the medical record did not contain an active physician order for oxygen therapy. The only oxygen order found in the record had been discontinued, and the MAR/TAR from June through September were blank for documented oxygen administration. Staff interviews indicated the resident needed oxygen continuously and that an order should have been in place. A second resident with COPD, asthma, and obstructive sleep apnea was documented as receiving oxygen on the MDS and was observed in bed with a nasal cannula connected to an oxygen concentrator set at 1.5 liters per minute. At the time of the observations, the active physician orders did not include an order for continuous or PRN oxygen. The care plan referenced oxygen use at 2 liters continuously, but the order to administer oxygen at 2 L/min was not documented in the EHR until after the observation. Nursing staff and the DON stated that oxygen should not be administered without a physician order specifying the liters per minute. The facility also failed to clean an oxygen concentrator filter for a resident with respiratory failure and heart failure. The resident was observed wearing a nasal cannula while the oxygen concentrator was running at 2 liters per minute, and the concentrator filter was covered with a thick white layer of dust. The resident's physician orders required the oxygen tubing, humidification bottle, storage bag, and filter to be changed or cleaned weekly, and the TAR showed the filter was last changed on 9/21/25. A clinical nurse consultant stated the filter did not appear to have been changed or cleaned as documented and said the facility's practice was to clean the filter weekly.
Improper Lidocaine Patch Administration and Documentation
Penalty
Summary
Safe, appropriate pain management was not provided for one resident with status-post left knee surgery and arthritis. The resident had intact cognition with a BIMS score of 15. On observation, the resident was awake in bed with two surgical dressings on the left knee and two lidocaine patches on the left leg, one on the medial side of the left knee and one on the left shin. The patch on the knee was dated 9/21 and the shin patch was undated. The resident stated that a nurse applied both patches on 9/21 and had not changed them since then, and said mild pain was present while expecting more pain medication that morning. The physician order for lidocaine 4% external patch directed application once daily for pain and removal per schedule, but did not specify placement location or authorize more than one patch. The MAR showed the patch was scheduled to be applied at 8:00 A.M. and removed the next day at 7:59 A.M., and documented patch changes on 9/21, 9/22, and 9/23. However, the surveyor observed the 9/21-dated patch still in place on 9/24. Unit Manager #1 stated she thought she had removed and reapplied a new patch on the knee but may have dated it 9/21, did not know why two patches were on the resident's leg, and said the admitting nurse should have clarified the order. The DON and Regional Nurse #2 later stated two patches were applied in error, one patch was misdated, the other was left undated, and the MAR incorrectly documented a patch change that did not occur.
Medications Left at Bedside Without Self-Administration Approval
Penalty
Summary
The facility failed to ensure medications were stored as required for one resident when a medication cup containing three white pills was observed on the resident’s bedside table while the resident was unsupervised by staff. The resident was cognitively intact with a BIMS score of 15 out of 15 and had diagnoses including cerebral infarction, contracture of the left hand, and depression. The resident stated the pills were morning medications that had not yet been taken. Review of the resident’s physician orders and care plan did not show that the resident had been approved to self-administer medications at the bedside. The facility’s Self-Administration of Medication BC-V5 assessment indicated the resident did not have medications to keep at bedside or wish to administer medications independently, and a later assessment was completed after the surveyor’s observation. Nursing staff stated the pills were the resident’s scheduled 6:00 A.M. Tylenol left by the overnight nurse, and that a self-administration assessment should have been completed before leaving the medications with the resident. The DON stated that when residents ask to self-administer medications, an assessment is completed at the bedside and provider approval is obtained before the resident is allowed to self-administer.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for four residents, leading to significant discrepancies in their documented health status. Resident #61 experienced a significant weight gain of 22.30% over six months, which was not accurately reflected in the MDS. The Regional MDS nurse acknowledged that this was a coding error, as the MDS should have indicated a significant weight gain. For Residents #41 and #59, the facility inaccurately coded their ability to be understood. Resident #41, whose primary language is Spanish, was marked as rarely/never understood on the MDS, despite being able to communicate with the aid of an interpreter. Similarly, Resident #59, who speaks Cantonese, was also marked as rarely/never understood, although they were able to communicate with the use of an interpreter. Interviews with the MDS Coordinator and the Psychiatric Nurse confirmed that these residents could communicate effectively with assistance, indicating a misrepresentation of their cognitive status on the MDS. Resident #32 was incorrectly coded as comatose on the MDS, despite observations and interviews indicating that the resident was awake, alert, and responsive at times. The medical record did not support a diagnosis of coma or persistent vegetative state, and staff interviews confirmed that the resident was not comatose. This coding error was acknowledged by the Regional MDS coordinator and the Director of Nurses, highlighting a significant oversight in the resident's assessment.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store medications securely and in accordance with professional principles, as observed by surveyors. On the first floor unit, two medication carts were left open and unattended, allowing potential access to medications by residents and staff. Additionally, a medication cup containing crushed medications mixed with applesauce was found unlabeled in the top drawer of a medication cart, with no indication of the medications it contained or the resident it was intended for. Nurse #1 admitted to placing the unlabeled medication cup in the drawer, acknowledging it was a mistake. On the second floor unit, a Levemir Flex Pen, which should be refrigerated until opened according to the manufacturer's instructions, was found warm and unopened in the top drawer of a medication cart. Nurse #2 was unaware of when the insulin pen was placed in the cart but confirmed it should have been stored in the refrigerator. These observations indicate a failure to adhere to the facility's medication management policy, which requires secure and proper storage of medications.
Failure to Complete SCSA After Hospice Disenrollment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who was discharged from hospice services. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, an SCSA is required when a resident discontinues hospice services, with the assessment reference date (ARD) needing to be within 14 days of the hospice revocation. The resident in question, admitted in November 2021 with dementia and a history of Covid-19, had a quarterly MDS assessment in March 2024 indicating they were receiving hospice services. However, by June 2024, the MDS assessment showed the resident was no longer receiving hospice services, with the hospice disenrollment date documented as April 19, 2024. Interviews with facility staff revealed a lack of awareness and action regarding the requirement for an SCSA following the resident's hospice service revocation. The Unit Manager acknowledged the resident's improvement and subsequent removal from hospice but was unaware of the need for an SCSA. The Regional MDS coordinator and the Director of Nurses, along with the Infection Preventionist, confirmed that an SCSA should have been completed but was not. This oversight indicates a failure in adhering to the required assessment protocols following a significant change in the resident's status.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brighton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spaulding Nursing And Therapy Center - Brighton | 0.8 mi | ★★★★★ | 0 | 0 |
| Care One At Brookline | 0.8 mi | ★★★★★ | 7 | 0 |
| Presentation Rehab And Skilled Care Center | 1.7 mi | ★★★★★ | 3 | 0 |
| Sherrill House | 1.8 mi | ★★★★★ | 9 | 0 |
| Watertown Rehabilitation And Nursing Center | 1.8 mi | ★★★★★ | 3 | 0 |
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