BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)

Official classification

Type A

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above by not ensuring that the bath mat in the memory care unit was non-slip, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/05/2026 Plan of Correction Staff removed the bath mat for the resident's bathroom during the inspection. Licensee/Administrator will conduct a staff training on non-slip/safety with staff and submit proof to LPA by Plan of Correction (POC) due date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above by not ensuring that the four bottles of cleaning solution were locked and inaccessible to memory care residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/05/2026 Plan of Correction Staff removed the cleaning solutions from underneath the sink in the kitchen and placed them in a locked storage room during the inspection. Licensee/Administrator will conduct an in-service training on dangerous items/storage and submit proof to LPA by Plan of Correction (POC) due date.

Official classification

Type B

Official code

87465(b)

Regulation authority

CCR

What the official deficiency says

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, Licensee/Administrator did not ensure that medications were not centrally stored which poses/posed a potential health, safety or personal rights risk to persons in care. Several bottles of medications were found in the bathroom cabinet of resident in room 224.

Official plan of correction

POC Due Date: 03/13/2026 Plan of Correction Staff removed all of the medicationos from the resident's room and logged them on the centrally stored medications list during the visit. Licensee/Administrator will conduct a staff training on centrally stored medications and notify residents' families regarding the facility's medication policy and submit proof to LPA by Plan of Correction (POC) due date.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including...an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met, as evidenced by: Based on interviews and records, facility staff did not immediately contact 9-1-1, rather staff contacted R1's hospice and began cooling measures for the resident. This posed an immediate threat to the health and safety of the resident in care.

Official plan of correction

The ED stated a policy was already in place regarding contacting emergency medical services when an incident occurred not involving a resident's hospice diagnosis. The ED stated an in-service was conducted regarding the policy and provided the LPA with a copy of the training. POC is cleared.

Deadline recorded: Dec 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements – General Facility personnel shall at all times be … and competent to provide the services necessary to meet resident needs. This requirement was not met, as evidenced by: Based on interviews and records the Licensee did not ensure facility personnel was competent to provide the services necessary to meet R1's needs. S1 did not demonstrate competency when they did not follow facility policy of observing R1 every 30 minutes, resulting in R1 sustaining 2nd degree burns. This posed an immediate threat to the health and safety of the resident in care.

Official plan of correction

The ED stated staff were in-serviced on 30-minute status checks, in addition to the installation of water misters & shading in outdoor areas used by residents. LPA received proof of the in-service training & observed the shading that was incorporated in the facility courtyard. POC is cleared.

Deadline recorded: Dec 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

...Assistance with self administered medications shall be limited to the following: Medications usually prescribed for self-administration which have been authorized by the person's physician. The facility did not meet this requirement as evidenced by providing R1 with the wrong dose of the medication Norco 09/11/2023 through 09/19/2023. This poses a potential health and safety risk for residents in care.

Official plan of correction

In addition to plan of correction measures implemented by the facility it is agreed that a pharmacy audit will be conducted by an outside pharmacy. Resident Care Coordinator agreed to provide scheduled date by POC due date of 10/04/2023 to complete the facility plan of correction. Copy of medication audit to be provided to CCL once completed.

Deadline recorded: Oct 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

HSC

What the official deficiency says

87465 Incidental Medical and dental care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care... (1) The licensee shall arrange or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: The Licensee failed to ensure that R1 received treatment for the wound in a timely manner. This posed a potential health, safety and personal rights risk to persons in care.

Official plan of correction

The Licensee agrees to conduct an inservice on skin breakdown, and body checks. Proof of completed POC is to be submitted to to the department by 5pm on the due date indicated.

Deadline recorded: Sep 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(b)

Regulation authority

CCR

What the official deficiency says

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement was not met evidenced by: LPA reviewed R1 medication administration records that are not the same as the medical order. Records further reveal that R1 was administered allergy medication for itching once on 08/11/23

Official plan of correction

Facility shall conduct a medication audit, specifically for creams and medication applied topically. Medication Technician training review to be completed and in-service record to be submitted to the DEpartment no later than end of POC date.

Deadline recorded: Aug 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Staff interviews that one scheduled medication is pre-poured. LPA observed pills for days 20 and 21 were not inside the medicine bubble pack.

Official plan of correction

Licensee shall conduct a random medication audit for 10 percent of the current population. Proof shall be submitted to the Department no later than the end of the POC date.

Deadline recorded: Oct 20, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

874659(d)(1)

Regulation authority

CCR

What the official deficiency says

If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms...Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication This requirement was not met as evidenced by: Records reviewed and staff interviews confirmed that Resident 1 (R1) scheduled medication ran out on 9/15/22 and the facility did not communicate with R1's family that the medication has not been filled until 10/5/22. This poses and immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall submit proof of training that residents are not without medication and that responsible parties are notified accordingly. Proof of the correction will be submitted to the Department before the end of POC date 10/13/2022. Prior to today's visit, Health Services Director verfiied that a re-training has been scheduled for med tech staff and will be completed no later than 10/20/2022.

Deadline recorded: Oct 13, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)(1)(B)

Regulation authority

CCR

What the official deficiency says

(i)(1)(B): Facilities shall have signal systems...All facilities licensed for 16 or more..Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal... This requirement is not met as evidenced by: Based on observation and interview, the licensee did not ensure that R1's call system was operable.

Official plan of correction

The licensee shall ensure R1's call button is operating or an alternative call system is available. The licensee has an operable call button for R1 as of 9/20/2021 1:01 PM.

Deadline recorded: Nov 19, 2021. A deadline is not proof that correction was completed.