Inspection Results » The Retreat at Brightwater

Health Inspection on March 11, 2018 ^[1]

1. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide and implement an infection prevention and control program. (Corrected 2018-04-10)

2. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (Corrected 2018-04-10)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-04-10)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-04-10)
   • Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne (Corrected 2018-04-10)

3. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-04-10)
   • Post nurse staffing information every day. (Corrected 2018-04-10)
   • Observe each nurse aide's job performance and give regular training. (Corrected 2018-04-10)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-04-10)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-04-10)
   • Keep all essential equipment working safely. (Corrected 2018-04-10)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-04-10)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-04-10)
   • Provide activities to meet all resident's needs. (Corrected 2018-04-10)
   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2018-04-10)
   • Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (Corrected 2018-04-10)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-04-10)
   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2018-04-10)

4. Widespread: No actual harm with potential for minimal harm

   • Encode each residentÂ’s assessment data and transmit these data to the State within 7 days of assessment. (Corrected 2018-04-10)