Inspection Reports for
Brightwater Senior Living of Highland

The facility was found to be operating within capacity and in good condition overall, with clean and sanitary premises. However, three deficiencies and two technical violations were cited related to safety and medication storage, including non-slip bath mats, locked storage of cleaning solutions, and improper medication storage in a resident's room.

The complaint was substantiated. Resident One was found outdoors, unresponsive with blisters, and later diagnosed with second degree sunburn. Staff One failed to observe the resident as required, and the allegation of neglect was validated.

The investigation substantiated that staff neglect occurred when Staff One failed to follow the facility's 30-minute observation policy, resulting in Resident One sustaining second degree sunburns. An immediate civil penalty of $500 was assessed.

The visit was triggered by complaint #18-AS-20200428122059. The complaint was substantiated based on interviews and records showing failure to seek timely medical attention for the resident.

The investigation revealed that a resident was found outside with second degree sunburn and blisters, and staff failed to immediately contact 911, instead contacting hospice and applying cooling measures. This failure posed an immediate threat to the resident's health and safety, resulting in a citation.

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 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 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.

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 complaint was substantiated. It was confirmed that a resident was given the wrong dose of narcotic pain medication without a physician's order, constituting a violation.

The investigation substantiated that the facility administered a higher dose (10 mg) of the medication Norco to a resident without a physician's order from 09/11/2023 through 09/19/2023, posing a potential health and safety risk. 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 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.

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.

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 investigation was substantiated regarding failure to apply ointment as prescribed, posing a potential health and safety risk to the resident. Other allegations about bathing and room cleanliness were unsubstantiated.

The complaint that staff did not apply ointment as prescribed was substantiated due to medication administration records not matching medical orders and missed administration of allergy medication. The allegations that staff did not bathe the resident and did not keep the resident's room clean were unsubstantiated based on observations and interviews.

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.

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 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.

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 that staff did not provide adequate supervision resulting in injury, did not meet toileting needs, did not administer medications as prescribed, did not seek timely medical attention, did not adhere to care plans, lacked skills to transport residents safely, and did not properly manage incontinence care resulting in infection. All allegations were unsubstantiated.

All allegations were found to be unsubstantiated after observations, staff and resident interviews, and records review. The investigation found no preponderance of evidence to prove the alleged violations occurred.

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.

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 not communicating to the responsible party that the medication ran out and was not filled for over two weeks, posing an immediate health and safety risk.

The complaint was substantiated as the facility failed to communicate with Resident 1's responsible party that a scheduled medication ran out from 9/15/22 through 10/4/22 and was not filled until 10/6/22, posing an immediate health and safety risk to residents.

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 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 lost property, unmet showering and hygiene needs, and rough handling of a resident. The call button was found broken and non-operational for a period, substantiating that allegation. Other allegations were unsubstantiated due to lack of evidence or resident refusal of services.

The investigation found one allegation substantiated regarding a broken resident call button that was not operable from 9/18/2021 to 9/20/2021. All other allegations related to staff response, personal hygiene, showering needs, and rough handling of the resident were unsubstantiated. No deficiencies were cited during this visit.

The complaint investigation was substantiated for medication administration errors and unclean resident bedroom. Other allegations including failure to respond to calls, failure to inform representatives of health changes, inadequate food service, verbal abuse, and failure to provide admission agreement copy were unsubstantiated or unfounded.

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

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.