THE RETREAT AT BRIGHTWATER
Inspection History Overview
Health Violations by Year
2023 2 violations
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
2022 7 violations
Respond appropriately to all alleged violations.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 necessary and PRN use is limited.
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Provide and implement an infection prevention and control program.
Perform COVID19 testing on residents and staff.
2020 4 violations
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Provide and implement an infection prevention and control program.
2019 16 violations
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Notify the resident or the residentβs representative in writing how long the nursing home will hold the residentβs bed in cases of transfer to a hospital or therapeutic leave.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide safe and appropriate respiratory care for a resident when needed.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure each residentβs drug regimen must be free from unnecessary drugs.
Provide timely, quality laboratory services/tests to meet the needs of residents.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
2018 17 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide activities to meet all resident's needs.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide enough food/fluids to maintain a resident's health.
Provide safe and appropriate respiratory care for a resident when needed.
Observe each nurse aide's job performance and give regular training.
Post nurse staffing information every day.
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 necessary and PRN use is limited.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide and implement an infection prevention and control program.
Keep all essential equipment working safely.
2017 7 violations
Provide care by qualified persons according to each resident's written plan of care.
Provide necessary care and services to maintain or improve the highest well being of each resident .
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Ensure residents maintain acceptable nutritional status.
Store, cook, and serve food in a safe and clean way.
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Have a program that investigates, controls and keeps infection from spreading.
Detailed Inspection Reports
No detailed inspection reports available yet. Check back soon as we're processing new reports daily.
Fines and Penalties by Year
2022 1 penalties totaling $57,825
2021 4 penalties totaling $4,586
2019 1 penalties totaling $13,905
Fire Safety Deficiencies
No description available