Brightwater Guest Home 3

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.This requirement was not met as evidenced by: Based on observation and record review the licensee did not comply with the section cited above. In R1's to R5's records were incomplete. R1 did not have: a Home Health Care Plan; a Doctor’s Order for Hoyer Lift & Half Bedrails. R2 and R3 did not have a Doctor’s Order for Half Bedrail. R4 did not have a Doctor’s Order for Half Bedrail & Hoyer Lift. R5 did not have a Doctor’s Order for Full Bedrail & Oxygen Machine.

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:(1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation.This was requirement was not met as evidenced by: Based on interviews conducted, three staff (S3, S4, and S5) and two witnesses (W1-W2) stated R1 was given a treatment when R1’s sustained a skin tear on the forearm on 4/29/2023. The topical medications applied to R1’s injured arm are called Calmoseptine and A&D. Based on record review, R1 has no prescription of Calmoseptine and A&D from a physician. This poses an immediate health, safety and/or personal rights risk to residents in care.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.This requirement was not met as evidenced by: Based on records review and interviews, the Resident’s authorized representative was not notified in writing of R1’s injury. A copy of the “Unusual Incident/injury Report” (LIC 624) was not provided to R1’s authorized representative. This poses a potential health, safety and/or personal rights risk to residents in care.