Caretel Inns Of Brighton
Inspection Findings
F-Tag F0689
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Level of Harm - Actual harm Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake 2660312Based on interview and record review, the facility failed to implement a resident-centered intervention which required a two-person total assist for positioning onto a bedpan for one (Resident R701) of one resident reviewed for falls, resulting in Resident R701 falling to the floor, sustaining a left clavicle (collarbone) fracture, new pain and discomfort to their left upper extremity.Findings include:A concern was filed with the State Agency alleging on 9/18/25 prior to being transferred for their weekly outpatient paracentesis (procedure that involves the removal of fluid from the abdomen) appointment, two family members and two EMT's (Emergency Medical Technician) personnel were waiting outside Resident R701's room while they (Resident R701) were cared for by one Certified Nurse Assistant (CNA) to use the bedpan. While waiting, Resident R701 was heard yelling I am going to fall, then a loud thump was heard and Resident R701 was found lying on the floor.Clinical record review revealed Resident R701 was admitted to the facility on [DATE REDACTED] for advanced end-stage liver disease with ascites (fluid accumulation in the abdominal cavity) that required weekly outpatient peritoneal paracentesis. Resident R701 had a Brief Interview of Mental Status (BIMS) score of 15/15 which indicated no cognitive impairment.Review of Resident R701's care plan dated 8/23/25 documented Resident R701 had a self-care deficit and had limited mobility. Resident R701 was assessed and required .extensive assist with 2 people for with use of bed pan for toileting.Record review of the EMS (Emergency Medical Service) report dated 9/18/25, documented: . EVENTS LEADING UP TO THE CALL: CREW WAS ORIGINALLY AT THE FACILITY TO TRANSPORT THIS PATIENT TO THE HOSPITAL FOR INTERVENTIONAL RADIOLOGY, HOWEVER THE PATIENT (PT) WAS ON A BEDPAN UPON ARRIVAL, THE NURSING ASSISTANT CAME INTO THE ROOM, AND THE CREW WAITED OUTSIDE OF THE ROOM FOR THE AIDE TO COMPLETE THE REMOVAL OF THE BEDPAN AND CLEAN UP OF THE PATIENT. THE CREW HEARD A LOUD SOUND RESEMBLING A FALL IN THE ROOM AND ENTERED, AND FOUND THE AIDE IN THE BATHROOM,
THE PATIENT WAS APPROXIMATELY 10 FEET AWAY, LAYING ON HER LEFT SIDE ON THE FLOOR.
THE PT HAD KNOCKED OVER FLOWERS AND A LAMP. PT COMPLAINED OF PAIN TO THE LEFT ARM.PT WAS TRANSPORTED TO HOSPITAL.Record review of the emergency room Radiology Report dated 9/18/25 at 11:33 AM confirmed Resident R701 had sustained a fracture to their left clavicle.Record review of a progress note authored by Physician C on 9/19/25 read Resident R701, .is in some pain associated with the collarbone fracture.On 11/12/25 at approximately 1:00 PM, The Director of Nursing (DON), Nursing Home Administrator (NHA), Assistant Director of Nursing (ADON) B and Nurse A who was assigned to Resident R701 on 9/18/25 were interviewed.Nurse A confirmed they were not in the room at time of incident and only one CNA (hereinafter CNA D) provided care to Resident R701.ADON B commented Resident R701 was care planned for two persons assist so they would have support to their enlarged abdomen due to ascites, not to roll off the alternating air mattress.The DON and NHA stated that CNA D who provided the care to R701was terminated because of the incident and review of the termination statement documented it was determined that the CNA D failed to follow care orders, follow the care plan designed to maintain Resident R701's safety which resulted in a fall with injury.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Caretel Inns of Brighton in Brighton, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Brighton, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Caretel Inns of Brighton or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.