Inspection Reports for Brightwater Senior Living of Highland

An unannounced complaint investigation visit was conducted in response to allegations received on 2024-03-15 regarding resident neglect and staff conduct at Brightwater Senior Living of Highland.

The investigation found the allegations unsubstantiated after interviews with staff and residents, observations, and document reviews. No evidence was found to support claims of residents being left unattended in soiled conditions, rough handling by staff, or untimely assistance.

The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.

An unannounced visit was conducted for the required annual inspection of the facility.

The facility was found to be operating within capacity and in good condition, with no deficiencies cited. The physical plant, kitchen and food service, medication management, resident and staff files, and operations and administration were all compliant with regulatory requirements.

Licensing Program Analyst Anna Bueno conducted an unannounced visit to this facility for a required annual inspection.

The facility was found to be operating within capacity and in good condition, clean, sanitary, and free of foul odors. No deficiencies were cited during this visit. Medications were dispensed according to physician's orders, and staff and resident files contained required documentation.

An unannounced complaint investigation was conducted following a complaint received on 04/28/2020 regarding a resident found injured outside the facility requiring hospitalization.

The investigation substantiated that staff neglect led to Resident One (R1) sustaining second degree sunburn due to failure to follow the facility's 30-minute observation policy. Staff One (S1) did not demonstrate competency, resulting in R1 being outside unsupervised and injured.

The complaint was substantiated. Resident One was found outside the facility with blisters and unresponsive, requiring hospitalization. Staff failed to observe the resident as required, leading to injury. An immediate civil penalty of $500 was assessed, with additional penalties under review.

The visit was an unannounced case management inspection to address a violation observed during the investigation of complaint #18-AS-20200428122059 involving a resident found outdoors with injuries and delayed medical attention.

The investigation found that staff failed to immediately contact 9-1-1 when a resident was found with second degree sunburn and signs of heat stroke, instead contacting hospice and applying cooling measures, which posed an immediate threat to the resident's health. A citation was issued for failure to seek timely medical attention.

The visit was triggered by complaint #18-AS-20200428122059 regarding a resident found outdoors with injuries and unresponsive condition. The complaint was substantiated based on interviews and records.

This unannounced visit was conducted to investigate a complaint alleging that staff mishandled a resident's medication while in care.

The investigation substantiated the complaint that a resident was given the wrong dose of the medication Norco (10 mg instead of the ordered 5 mg) without a physician's order from 09/11/2023 through 09/19/2023. The facility implemented a plan of correction including medication cart audits and staff training.

Complaint was substantiated. The allegation that staff mishandled a resident's medication by administering an incorrect dose without a physician's order was found valid.

The inspection was an unannounced complaint investigation visit triggered by an allegation of neglect by staff resulting in a resident sustaining a pressure injury while in care.

The investigation found sufficient evidence to substantiate neglect by facility staff in providing proper care and supervision to Resident #1, who developed a pressure injury that was not treated timely or properly. Nine care staff received written warnings for not being aware of the wound, and an immediate civil penalty of $500 was assessed.

The complaint was substantiated. The allegation was neglect by staff resulting in a resident sustaining a pressure injury. The investigation included observations, interviews, and records review, confirming neglect and failure to follow medical orders.

An unannounced complaint investigation was conducted following a complaint received on 08/07/2023 alleging that staff did not apply ointment as prescribed, did not bathe a resident, and did not keep a resident's room clean.

The investigation substantiated the allegation that staff did not apply ointment as prescribed, posing a potential health and safety risk. The allegations that staff did not bathe the resident and did not keep the resident's room clean were unsubstantiated.

The complaint investigation was substantiated regarding failure to apply ointment as prescribed. The allegations that staff did not bathe the resident and did not keep the resident's room clean were unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate allegations including unexplained injury to a resident, residents being left in soiled diapers, neglect, and failure to provide clean linens.

All allegations were found to be unsubstantiated after observations, interviews with staff and residents, and records review. Residents were observed to be clean and well cared for, and no evidence supported the complaints.

The complaint investigation was unsubstantiated. Allegations included unexplained injury, residents left in soiled diapers, neglect, and failure to provide clean linens. Interviews and observations did not support these allegations.

The visit was an unannounced complaint investigation regarding resident 1 (R1) related to complaint investigation number 56-AS-20221102154307.

The Licensing Program Analysts interviewed the resident and met with the facility administrator who informed them that the resident was moved to another facility due to needing a higher level of care. Details of the resident's needs were discussed and the new facility information was provided.

Complaint investigation 56-AS-20221102154307 was conducted. The resident was no longer at the facility as they had been moved to another facility requiring a higher level of care.

Licensing Program Analyst Anna Bueno conducted an unannounced case management visit regarding a report received by the Department on 2023-01-20 about the placement of Resident 1 and an allegation that Resident 1 was yelled at by staff.

The visit found that Resident 1 was not yelled at by staff on 2023-01-20; Resident 1 was on an outing when an incident occurred. The facility has been trying to contact Resident 1's responsible party to seek a more appropriate setting. No deficiencies were cited during the visit.

The visit was an unannounced case management incident investigation conducted to discuss an incident report received by the Department on 12/13/22 involving staff behavior towards a resident on 12/8/22.

The investigation found that Staff 1 was observed yelling and holding a resident's arm aggressively, and subsequently threatened the resident. Staff 1 was separated from the facility as of 12/14/22. No deficiencies were cited during the visit.

The complaint involved Staff 1 yelling at and holding the arm of Resident 1, followed by a threat to hurt the resident. Staff 1 was separated from the facility and did not return to work after 12/8/22. No deficiencies were cited.

An unannounced complaint investigation visit was conducted to investigate multiple allegations regarding inadequate supervision, toileting care, medication administration, timely medical attention, adherence to care plan, safe resident transport, and incontinence care at Brightwater Senior Living of Highland.

All allegations were found to be unsubstantiated after observations, staff and resident interviews, and records review. However, a Type B deficiency was cited for improper medication storage, specifically that one scheduled medication was pre-poured and pills for certain days were not inside the medicine bubble pack.

The complaint included allegations of inadequate supervision resulting in injury, unmet toileting needs, improper medication administration, delayed medical attention, non-adherence to care plan, unsafe resident transport, and improper incontinence care resulting in infection. All allegations were investigated and found unsubstantiated.

An unannounced visit was conducted to deliver an amended report related to complaint control number 56-AS-20221013102111.

The findings for the complaint control number remain unsubstantiated. No deficiencies were cited during the visit.

Complaint control number 56-AS-20221013102111 was investigated and found to be unsubstantiated.

The inspection was an unannounced visit to investigate a complaint alleging that the facility mismanaged a resident's medications.

The complaint was substantiated as the facility failed to communicate with Resident 1's responsible party that a scheduled medication ran out and was not filled for an extended period, posing an immediate health and safety risk to residents.

The complaint was substantiated. The facility mismanaged Resident 1's medications by failing to notify the responsible party that the medication ran out on 9/15/22 and was not filled until 10/6/22. This posed an immediate health and safety risk to residents in care.

An unannounced complaint investigation was conducted in response to allegations received on 08/17/2022 regarding eviction letter errors, failure to provide resident reappraisal, and staff interference with resident obtaining medical care.

The investigation found all allegations to be unsubstantiated or unfounded, meaning there was insufficient evidence to prove violations occurred. The eviction letter contained correct information, reappraisal was provided, and staff did not interfere with resident medical care.

The complaint investigation addressed three allegations: 1) staff served a resident an eviction letter containing incorrect information, 2) staff did not provide resident with reappraisal, and 3) staff interfered with resident obtaining medical care. All allegations were found to be unsubstantiated or unfounded.

Licensing Program Analysts conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on the infection control domain.

No health and safety concerns were observed at the time of the visit, and no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. The facility demonstrated compliance with infection control measures including COVID-19 mitigation plans, symptom screening, PPE supply, and fire safety maintenance.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 09/22/2021 regarding staff response to resident calls for help, reimbursement for lost property, resident showering and hygiene needs, and rough handling of a resident.

The investigation found one allegation substantiated: the resident's call button was broken and not operable between 9/18/2021 and 9/20/2021. All other allegations regarding staff response, reimbursement, showering, personal hygiene, and rough handling were unsubstantiated. A deficiency was cited for failure to ensure an operable call system.

The complaint investigation was triggered by allegations including staff not responding to resident calls, failure to reimburse for lost property, unmet showering and hygiene needs, and rough handling of a resident. The call button being broken was substantiated; other allegations were unsubstantiated.

The inspection visit was an Annual/Required Visit conducted to evaluate the facility's compliance with regulations, including infection control procedures during the COVID-19 pandemic.

The facility was found to be in compliance with infection control procedures, including proper use of PPE, social distancing during meals and entertainment, and adequate training on COVID prevention. No citations or technical violations were issued.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 12/22/2020 regarding medication administration, cleanliness, communication, food service, injuries, verbal abuse, and admission agreement issues at Brightwater Senior Living of Highland.

The investigation substantiated two allegations: failure to administer resident's medication per physician orders and failure to maintain the resident's bedroom clean. Several other allegations including failure to promptly respond to calls, failure to inform representatives of health changes, inadequate food service, verbal abuse, injuries caused by staff, and failure to provide admission agreement copy were found unsubstantiated or unfounded.

The complaint investigation was substantiated for allegations that facility staff did not administer resident's medication per physician orders and did not clean the resident's bedroom. Other allegations including failure to respond to calls, failure to inform representatives of health changes, inadequate food service, verbal abuse, injuries caused by staff, and failure to provide admission agreement copy were unsubstantiated or unfounded.