Brightwater Senior Living of Highland (DBA)

Allegation investigated: Staff handled resident in a rough manner. Staff yelled at a resident in care. Staff made inappropriate comments towards a resident in care. Staff did not dispose of resident's trash bin. Staff did not ensure that resident received laundry services. Staff are not following resident's hospice care plan. Staff did not ensure that resident's room is cleaned. Staff are not practicing proper hygiene in between cleaning. Staff did not notify resident's responsible party of an incident in a timely manner.

On 04/28/2026 at 1:20PM Licensing Program Analyst (LPA) Renese Howell-Small arrived unannouced to the facility to deliver findings for the above allegations. LPA was greeted by staff, introduced self and stated the purpose if the visit. LPA met with Executive Director, Marguerite Crockem. Resident 1 (R1) was discharged from the facility on 02/14/2026 and recently passed away. The allegation of staff handled resident in a rough manner: LPA interviewed eight (8) staff and five (5) residents. Staff denied the allegation and stated that the residents would inform staff and relatives if this occurred. The residents denied the allegation, stating that they have not observed staff handle residents in a rough manner. Based on interview, this allegation is UNSUBSTANTIATED. The allegation that staff yelled at a resident in care: LPA interviewed staff, residents and a relative of Resident 5 (R5). Staff and residents denied the allegation and stated that they have not witnessed staff yell at residents. Based on interview, this allegation is Unsubstantiated UNSUBSTANTIATED. The allegation that staff made inappropriate comments towards a resident in care: LPA interviewed eight (8) staff and five (5) residents. Both the staff and the residents denied the allegation. Based on interview and limited information, this allegation is UNSUBSTANTIATED. The allegation that staff did not dispose of resident's trash bin: LPA toured the facility and did not observe residents' trash bin to be full. Residents stated that staff empty their trash daily. Staff stated that trash is emptied as often as needed. Based on observation and interview, this allegation is UNSUBSTANTIATED. The allegation that staff did not ensure that resident received laundry service: LPA observed a laundry schedule which lists the rooms and the day laundry will be completed. Staff stated that laundry is completed weekly or more if needed. The residents stated that staff take care of their laundry. Based on observation and interview, this allegation is UNSUBSTANTIATED. The allegation that staff are not following resident's hospice care plan: LPA was unable to review Resident 1 (R1) hospice care plan as they discharged from the facility on 02/14/2026. Staff denied the allegation and stated that they are trained to follow the residents' care plan. Based on limited information and interview, this allegation is UNSUBSTANTIATED. The allegation that staff did not ensure that resident's room is cleaned: On 02/09/2026, LPA observed R1's room to be clean and free from malodors. Both staff and residents denied the allegation and stated that rooms are cleaned every week. Based on observation and interview, this allegation is UNSUBSTANTIATED. The allegation that staff are not practicing proper hygiene in between cleaning: Staff stated that they are trained in proper hand hygiene. Staff denied the allegation. Based on limited information and interview, this allegation is UNSUBSTANTIATED. The allegation that staff did not notify resident's responsible party of an incident in a timely manner: Staff stated that the appropriate parties are notified when incidents occur. Staff denied the allegation. The relative of R5 stated that staff communicate with the family regarding incidents. Staff notified the family of R1 the day of the incident. Based on record review and interview, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted where this report LIC9099 and LIC9099C were discussed and copies were provided to Executive Director, Marguerite Crockem.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 56-AS-20260204160515

Type of visit: Case Management - Other

On 03/30/2026 at 9:45AM Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to the facility in order to conduct a Plan of Corrections visit for the annual inspection completed on 03/04/2026, obtain documentation and complete interviews with staff and residents related to complaint #56-AS-202602041600515. LPA met with Executive Director, Marguerite Crockem and stated the purpose of the visit. The Plan(s) of Correction were complete and clearance letters will be final printed and forwarded to the Executive Director. An exit interview was conducted where this report LIC809 was discussed and a copy provided the Executive Director, Marguerite Crockem.the state’s words, verbatim · CDSS document, Mar 30, 2026

Type of visit: Required - 1 Year

On 03/04/2026 at 09:30AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to this facility for the required annual inspection. Entry into the facility is unobstructed and LPA met with Health Services Director, Amber Nelson. The facility is approved for a Hospice Waiver for twenty (20) residents. The facility is approved for delayed egress. LPA and maintenance manager Enrique Serralta toured the exterior of the facility. Physical Plant: The facility is operating within capacity and not beyond the conditions of the license. There are no pool located on the premises. There is a shallow potted water feature in the memory care courtyard. The facility is being maintained at a comfortable temperature for residents in common areas. Residents are able to set individual temperatures within their unit. All passageways are kept free of obstruction. Hot water temperature was measured in five units at random and all measured within regulatory limits. There are grab bars for each toilet, bathtub and showers used by residents. The facility has an operable signal system that is operable from the memory care unit. Fire safety installations such as extinguishers, sprinklers, and alarms are monitored by an authorized fire inspection outside company and LPA observed proof of inspection during the inspection on 03/04/2026. The commercial kitchen was last inspected by the same third party company on 10/24/2024. Fire extinguishers were observed to be charged, last serviced on 03/23/2025 and will be serviced at the end of the month. Overall the facility is in good condition; it is clean, sanitary and free of foul odors. Kitchen and Food Service: The total daily diet provided to residents appears to be of the quality and in the quantity necessary to meet resident needs. There is a minimum of one week supply of nonperishable foods and two days of perishable food items. All readily perishable food or beverages capable of micro-organism growth are being stored in covered containers at appropriate temperatures. Commercial refrigerator and freezer are maintained within regulatory temperatures. Medication, Care, and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs. Chemicals and items which may pose a danger were observed in an unlocked cabinet in the memory care kitchen. A deficiency will be cited. LPA Renese Howell-Small inspected medications with charge nurses and found medications in their original containers. Medications appear to be dispensed according to the physician's orders. LPA observed over-the-counter medications in one of the residents' room. A deficiency will be cited. Resident and Staff Files: LPA reviewed a sample of staff and resident files. Staff files had the required documentation including a health screening report and current first aid and/or CPR certification. Resident files had the required documentation including consent forms, appraisal and/or needs and services plan, and updated physician's reports. Two (2) of the resident files reviewed did not have Admission's Agreement. A Technical Violation was cited. First Aid training are on file for staff who provide direct care and supervision to residents. Staff have training for Dementia care and Activities of Daily Living. Operations and Administration: Disaster Plan is present. Executive Director Marguerite Crockem is present in the facility a sufficient amount of hours and the administrator certification is up to date. The required licensing and ombudsman posters are posted and in public view. Residents rights are posted and a copy is kept in the resident's file. Three deficiencies and two Technical Violations were cited during this visit. LPA confirmed that licensing fees are current. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed and copies provided to staf, Sarina Alonso.the state’s words, verbatim · CDSS document, Mar 4, 2026

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Licensee does not ensure sufficient staffing to meet residents’ care needs. Licensee does not ensure staff are appropriately trained to provide care to residents.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator and explained the purpose of the visit. The investigation consisted of interviews, review of records, and observations. First allegation: Licensee does not ensure sufficient staffing to meet residents’ care needs. Regarding the allegation LPA reviewed facilities staff directory and observed that the facility has sufficient staff that will meet resident care needs daily. LPA conducted interviews with R#1, R#2, R#3, R#4, and R#5, regarding the alleged allegation and five out of five residents informed LPA that facility has enough care support to meet their care needs. In addition, five out of five residents informed LPA that facility provides good laundry services as well as housekeeping services. R#1-5 informed LPA that they feel safe and caregivers respond to their call services right away. R#1-5 denied witnessing staff not providing proper care and denied witnessing residents being mistreated by caregivers while in care. Five out of five residents informed LPA that their showering needs along with their incontinence needs are met daily and they have no concerns to report. Unsubstantiated Second allegation: Licensee does not ensure staff are appropriately trained to provide care to residents. Regarding the allegation, LPA conducted a record review pertaining to catheter training LPA observed that facility utilizes Home Health services to assist with catheter flushing, removal, and catheter insertion. LPA conducted interviews with S#1 and S#2 regarding catheter training and S#1, and S#2 informed LPA that caregivers are only provided training on how to only drain catheters and observe for any change of condition. LPA conducted interviews with R#1-5 LPA went over the alleged allegation and all residents informed LPA that they feel safe and all staff that provide care seem aware of what they are doing and provide care as trained professionals. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator at the end of the visit.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 56-AS-20241107140947

Allegation investigated: Resident was left unattended in urine and feces for extended periods, resulting in bedsores Staff handled resident roughly, resulting in an injury Staff did not assist resident in a timely manner

Licensing Program Analysts (LPA) Becky Mann and Edith Conchas conducted an unannounced visit to the facility to initiate a complaint investigation. LPAs met with Marguerite Crockem, Administrator and explained the purpose of today's visit. The investigation consisted of LPAs observations, pertinent document reviews, and interviews with staff and residents. The allegation that resident was left unattended in urine and feces for extended periods, resulting in bedsores. Five (5) staff interviewed denied leaving resident(s) unattended in urine and feces for extended periods, resulting in bedsores. Four (4) of five (5) residents interviewed stated that staff has not left them unattended in urine and feces for extended periods. Based on LPAs observations while interviewing the resident's in their rooms, LPAs did not observe resident's in soiled clothing and linens. There was no unpleasant odor observed by LPAs. Unsubstantiated The allegation that staff handled resident roughly, resulting in an injury. Five (5) staff interviewed denied handling resident roughly, resulting in an injury. Five (5) residents interviewed stated that staff does not handle residents roughly, if it were to happen then the resident would speak up for themselves. The allegation that staff did not assist resident in a timely manner. Five (5) staff interviewed stated that they do assist residents in a timely manner. Residents have a pendant which they use to call the staff. Staff stated it takes about 7 to 10 minutes to assist the resident. Five (5) residents interviewed stated that staff does assist resident in a timely manner. Most of the residents stated it takes about 15 minutes to receive assistance from the staff. Based on evidence obtained during this investigation, the allegations above are Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy of this report was provided to Marguerite Crockem, Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 12, 2025 · control 56-AS-20240315160632

Type of visit: Required - 1 Year

On 03/18/2025 at 10:05AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to this facility for the required annual inspection. Entry into the facility is unobstructed and LPA met with Executive Director (ED) Marguerite Crockem. The facility is approved for a Hospice Waiver for twenty (20) residents. The facility is approved for delayed egress. LPA and maintenance manager Enrique Serralta toured the exterior of the facility. Physical Plant: The facility is operating within capacity and not beyond the conditions of the license. There are no pools or other bodies of water located on the premises. The facility is being maintained at a comfortable temperature for residents in common areas. Residents are able to set individual temperatures within their unit. All passageways are kept free of obstruction. Hot water temperature was measured in five units at random and all measured within regulatory limits. There are grab bars for each toilet, bathtub and showers used by residents. The facility has an operable signal system that is operable from the memory care unit. Fire safety installations such as extinguishers, sprinklers, and alarms are monitored by an authorized fire inspection outside company and LPA observed proof of inspection completed on 10/24/2024. The commercial kitchen was last inspected by the same third party company on 10/24/2024. Fire extinguishers were observed to be charged. Overall the facility is in good condition; it is clean, sanitary and free of foul odors. Kitchen and Food Service: The total daily diet provided to residents appears to be of the quality and in the quantity necessary to meet resident needs. There is a minimum of one week supply of nonperishable foods and two days of perishable food items. All readily perishable food or beverages capable of micro-organism growth are being stored in covered containers at appropriate temperatures. Commercial refrigerator and freezer are maintained within regulatory temperatures. Kitchen hood was last inspected by the same outside company on 10/24/2024. Medication, Care, and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs. Chemicals and items which may pose a danger are stored inaccessible to residents. LPA Renese Howell-Small inspected medications with charge nurses and found medications in their original containers. Medications appear to be dispensed according to the physician's orders. Resident and Staff Files: LPA reviewed a sample of staff and resident files. Staff files had the required documentation including a health screening report and current first aid and/or CPR certification. Resident files had the required documentation including admission's agreement, consent forms, appraisal and/or needs and services plan, and updated physician's reports. First Aid training are on file for staff who provide direct care and supervision to residents. Staff have training for Dementia care and Activities of Daily Living. Operations and Administration: Disaster Plan is present. Executive Director Marguerite Crockem is present in the facility a sufficient amount of hours and the administrator certification is up to date. The required licensing and ombudsman posters are posted and in public view. Residents rights are posted and a copy is kept in the resident's file. No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809C was discussed and provided to the Executive Director.the state’s words, verbatim · CDSS document, Mar 18, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility for a required annual inspection. Entry into the facility is unobstructed and LPA met with Executive Director (ED) Marguerite Crockem. The facility is approved for a Hospice Waiver for twenty (20) residents. The facility is approved for delayed egress. LPA and maintenance manager Enrique Serralta toured the interior of the facility. Inclement weather prohibited touring the facility's exterior but can be observed through windows throughout the facility. Physical Plant: The facility is operating within capacity and not beyond the conditions of the license. There are no pools or other bodies of water located on the premises. The facility is being maintained at a comfortable temperature for residents for common areas. Residents are able to set individual temperatures within their unit. All passageways are kept free of obstruction. Hot water temperature was measured in five units at and random all measured within regulatory limits. There are grab bars for each toilet, bathtub and showers used by residents. The facility has an operable signal system that is operable from the memory care unit. Fire safety installations such as extinguishers, sprinklers, and alarms are monitored by an authorized fire inspection outside company and LPA observed proof of inspection completed on 03/22/23, 01/23/24, and 12/08/23, respectively. The commercial kitchen was last inspected by the same third party company on 09/20/23. Fire extinguishers were observed to be charged. Overall the facility is in good condition; it is clean, sanitary and free of foul odors. Kitchen and Food Service: The total daily diet provided to residents appears to be of the quality and in the quantity necessary to meet resident needs. There is a minimum of one week supply of nonperishable foods and two days of perishable food items. All readily perishable food or beverages capable of micro-organism growth are being stored in covered containers at appropriate temperatures. Commercial refrigerator and freezer are maintained within regulatory temperatures. Kitchen hood was last inspected by the same outside company on 09/20/23. Medication, Care, and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs. Chemicals and items which can constitute a danger are stored inaccessible to residents. LPA Anna Bueno inspected medications with charge nurse and found medications in their original containers. Medications appear to be dispensed according to the physician's orders. Resident and Staff Files: LPA reviewed a sample of staff and resident files. Staff files had the required documentation including a health screening report and current first aid and/or CPR certification. Resident files had the required documentation including admission's agreement, consent forms, appraisal and/or needs and services plan, and updated physician's reports. First Aid training are on file for staff who provide direct care and supervision to residents while current CPR certification id present for nursing staff. Staff have training for Dementia care and Activities of Daily Living. Operations and Administration: Disaster Plan is present. Executive director Marguerite Crockem is present in the facility a sufficient amount of hours and their administrator certification is up to date. The required licensing and ombudsman posters are posted and in public view. Residents rights are posted and a copy is kept the resident's file. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the Executive Director.the state’s words, verbatim · CDSS document, Feb 6, 2024

Allegation investigated: Resident was found injured outside the facility requiring hospitalization

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPA met with Executive Director, Marguerite Crockem, and informed her of the purpose for her visit. The Department investigation consisted of interviews, a review of resident records, and medical records. It was alleged staff neglect led to Resident One (R1) being injured and requiring hospitalization. Interview revealed, R1 was found on 04/24/2020, outdoors, on the facility premises. The exact time of when R1 was found could not be determined. It was reported R1 was found sometime between 2:15pm and 2:50pm. It was reported R1 was outside, sitting in a chair, directly in the sun, and unresponsive. R1 was observed with blisters on the leg, arms, hands, and elbows. It was reported when staff removed R1’s clothing, R1’s blisters popped. Substantiated During the course of the investigation, Staff One (S1) could not be interviewed. Staff interviews revealed, the facility has a policy to observe and document resident’s whereabouts every 30 minutes. Staff are required to submit a Thirty Minute Log which includes the room number of every resident they are assigned to. The staff are required to document where in the facility the resident is located on this log, when they make their observation. S1 was assigned to supervise R1 on 04/24/2020. A review of the Thirty Minute Log, which included R1’s room number, dated 04/24/2020, revealed, R1 was seen in the TV room, every 30 minutes, starting at 12:30pm until 2:30pm. One staff interview revealed, S1 made a statement that they had last seen R1 at 1:45pm when they provided a service to R1. Staff interviews contradicted the Thirty Minute Log filed by S1. S1 was last observed at 1pm, when they left the unit they were assigned, to participate in a staff celebration and was not seen returning to the unit until 2pm. Staff interviews did not reveal the last time R1 was observed. Staff interview revealed that R1 had not been seen during lunch, which is between 11am and 11:30am. The investigation shows R1 was outside for an unspecified amount of time. Discharge Summary from the hospital, dated 04/28/2020, revealed R1 was diagnosed with Second Degree Sunburn. This allegation is deemed 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 during today’s visit. 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 where this report, LIC9099D, LIC 811, LIC421IM, and appeal rights were discussed and provided to the Executive Director.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 18-AS-20200428122059

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 1, 2023

Personnel Requirements – General Facility personnel shall at all times be … and competent to provide the services necessary to meet resident needs. This requirement was not met, as evidenced by: Based on interviews and records the Licensee did not ensure facility personnel was competent to provide the services necessary to meet R1's needs. S1 did not demonstrate competency when they did not follow facility policy of observing R1 every 30 minutes, resulting in R1 sustaining 2nd degree burns. This posed an immediate threat to the health and safety of the resident in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: The ED stated staff were in-serviced on 30-minute status checks, in addition to the installation of water misters & shading in outdoor areas used by residents. LPA received proof of the in-service training & observed the shading that was incorporated in the facility courtyard. POC is cleared.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to address a violation observed during the investigation of complaint #18-AS-20200428122059. The LPA met with Executive Director, Marguerite Crockem, and informed her of the purpose for her visit. The investigation revealed R1 was found on 04/24/2020, outdoors, on the facility premises, with observable injuries. The exact time of when R1 was found could not be determined. It was reported R1 was found sometime between 2:15pm and 2:50pm. Interviews reported R1 was outside, sitting in a chair, directly in the sun, and unresponsive. Interviews revealed R1 was observed with blisters on the leg, arms, hands, and elbows. Staff One (S1) reported R1's condition did not rise to a level of an emergency and the hospice agency was contacted instead, per facility protocol. Interviews revealed S2 told the caregivers to take R1 to the shower to cool the resident down. R1's hospice nurse documented receiving a call from the facility at 3:30 pm reporting that R1 seemed to have had a “heat stroke” and cooling measures were being done. The Nurse arrived at the facility at 4:20 pm and found R1 in bed unresponsive, with cooling measures being done. According to the Nurse, R1 still felt hot to the touch and their temperature was at 103.5 ⁰F. The Nurse stated that 911 was called during their visit. It was reported that when paramedics arrived, R1 started to seize as they were being transported to the hospital. A Discharge Summary from the hospital, dated 04/28/2020, revealed R1 was diagnosed with Second Degree Sunburn. Therefore, based on interviews and records, a citation will be issued due to failure to seek timely medical attention. An exit interview was conducted where this report, LIC 809D and appeal rights were discussed and provided to the Executive Director.the state’s words, verbatim · CDSS document, Nov 30, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Dec 1, 2023

Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including...an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met, as evidenced by: Based on interviews and records, facility staff did not immediately contact 9-1-1, rather staff contacted R1's hospice and began cooling measures for the resident. This posed an immediate threat to the health and safety of the resident in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: The ED stated a policy was already in place regarding contacting emergency medical services when an incident occurred not involving a resident's hospice diagnosis. The ED stated an in-service was conducted regarding the policy and provided the LPA with a copy of the training. POC is cleared.

Allegation investigated: Staff mishandled a resident's medication while in care

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 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.the state’s words, verbatim · CDSS document, Oct 4, 2023 · control 56-AS-20230926135046

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5)(A) · Plan of correction due date: Oct 5, 2023

...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 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.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: 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. 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.