366426055-9-12-2023-18-AS-JDHS-CVZTMT-20230925145139

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426055
Report Date: 09/12/2023
Date Signed: 09/12/2023 02:42:27 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/26/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200226162945

FACILITY NAME:	BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)		FACILITY NUMBER:	366426055
ADMINISTRATOR:	MARGUERITE CROCKEM		FACILITY TYPE:	740
ADDRESS:	28807 BASELINE STREET		TELEPHONE:	(909) 742-7353
CITY:	HIGHLAND	STATE: CA	ZIP CODE:	92346
CAPACITY:	115	CENSUS: 91	DATE:	09/12/2023
		UNANNOUNCED	TIME BEGAN:	01:13 PM
MET WITH:	Marguerite Crockem, Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Neglect by staff resulting in a resident sustaining a pressure injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made and unannounced visit to deliver findings for the allegation noted above. LPA met with Execuitve Director Marguerite Crockem and explained the purpose of the visit and the elements of the allegation. The department investigated the allegation, the investigation consisted of observations, interviews and records review.

Resident #1 (R1) was admitted to the facility on 05/02/2014 without any noted pressure injuries or wounds. On 01/02/2020, Staff #1 (S1) reported to the Residential Care Manager (S2) that R1 had a wound located on their left heel and described it as "an about a 3-inch by 3-inch circle with blackness inside the circle and redness around it". After seeing the wound, S2 did nothing and waited until the following day. At that time is when S2 assessed the area, then notified R1’s responsible party, and spoke with them about R1 receiving hospice services. However, there was no additional follow up with R1’s Primary Care Physician. Interview revealed S2 believed a fax had already been sent to the Doctor. *** Continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200226162945

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)	FACILITY NUMBER: 366426055
	VISIT DATE: 09/12/2023

NARRATIVE

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On 01/03/2020, the doctor gave orders to keep the foot elevated in order to release pressure and asked to see photographs. Per the Acting Executive Director, a photo was not sent as they believed it would be a HIPPA violation. Additional interviews revealed, Staff # 3 (S3) revealed that they would change and adjust R1’s socks but would not check R1’s heels. S3 observed red stains in R1’s bedding but did not check to see where it was coming from. S3 assumed R1 had an ingrown toenail. R1 was known to pick their skin and S3 assumed the blood could have been from that as well. Investigation did not reveal that facility staff followed the doctor’s request to evaluate or stage the pressure injury/wound. Investigation revealed that between 01/02/2020 through 01/07/2020, R1 was reported to not receive any treatment for the wound on their left heel other than having their foot elevated and the area cleaned by facility staff. Per S2, staff are responsible for conducting skin integrity checks during resident showers. R1 received showers twice a week until they were admitted to hospice on January 7, 2020. However, staff did not report seeing any skin integrity issues until 01/02/2020. This resulted in nine (9) care staff receiving written warnings for not being aware of the wound.

On 01/07/2020, hospice services were initiated, and the nurse assessed the wound. At this time the wound was described as an "unstageable decubitus ulcer to the right heel" that was about 6 cm (2.36 inches) by 6 cm (2.36 inches) and it was covered by necrotic tissue. S1 was present during the assessment and stated that "the wound looked the same as it did on 01/02/2020”.

There is sufficient evidence to show neglect by facility staff, to provide proper care and supervision of R1. Therefore, the allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An immediate civil penalty of $500 is being assessed. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.

An exit interview was conducted, a copy of this report was reviewed and provided along with the 9099C, 9099D, appeal rights, and LIC421IM was given to Executive Director Marguerite Crockem.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200226162945

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)	FACILITY NUMBER: 366426055
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/26/2023 Section Cited HSC 87465(a)(1)	1 2 3 4 5 6 7	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	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

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