366426055-10-4-2023-56-AS-NBRN-CWNRD9-20231016125532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426055
Report Date: 10/04/2023
Date Signed: 10/04/2023 11:28:05 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/26/2023 and conducted by Evaluator Amy Goldenberg

COMPLAINT CONTROL NUMBER: 56-AS-20230926135046

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:	10/04/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Ruth Villa, Resident Care Manager		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff mishandled a resident's medication while in care

INVESTIGATION FINDINGS:

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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is to initiate the 10 day visit to investigate the above-mentioned complaint allegation. LPA met with Resident Care Coordinator Ruth Villa, LVN and disclosed the elements of the complaint investigation. Investigation consisted of interview with Ruth Villa and review of the records for one (1) resident (R1). It is alleged that R1 was given the wrong dose of a narcotic pain medication. Interview with Resident Care Coordinator revealed that the allegation is accurate. R1 had a routine order for 5 mg of the medication Norco. On 09/11/2023 a nurse dropped off medication intended for R1 as post-operative pain management for after a scheduled upcoming surgery. The medication received by the facility was for 10 mg of the medication Norco, and did not have a physicians order or direction provided. The facility mistakenly thought that the medication was a refill of the 5 mg routine order of the medication Norco. The facility administered the 10 mg dose of Norco with out an order from 09/11/2023 through 09/19/2023 at 2200.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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 56-AS-20230926135046

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)	FACILITY NUMBER: 366426055
	VISIT DATE: 10/04/2023

NARRATIVE

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The facility has provided their plan of correction to LPA which has been implemented and was to conduct an in-house medication cart audit. The facility has implemented three (3) weekly inter-shift medication cart audits. The facility has conducted an in-service training to all medication technicians/nurses on 09/25/2023.

Based on the available information the complaint allegation is being substantiated. LPA has determined the complaint allegation as valid and that a violation has occurred. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230926135046

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)	FACILITY NUMBER: 366426055
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/05/2023 Section Cited CCR 87465(a)(5)(A)	1 2 3 4 5 6 7	...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	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14	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.
	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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

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