The Brightpointe

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 17 residents (Resident #30, #31, and #97) reviewed for care plans. -The facility failed to develop and implement a comprehensive care plan for Resident #30 for cardiac telemetry status (a monitoring system that tracks electrical activity of the heart using electrodes and a monitor). -The facility failed to develop and implement a comprehensive care plan for Resident #30, #31, and #97 for the use of bedrails. This deficient practice could place residents at risk of not receiving proper care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident was free from misappropriation of property for 4 of 5 residents (Resident #1. CR #1, CR #3 and CR #4) reviewed for misappropriation of property. - The facility failed to ensure that LVN A did not misappropriate CR #1's Tylenol #3 over a 3-month period (June 2023 to August 2023). - The facility failed to have a system in place to identify drug diversion of controlled substances and to take action on the pharmacist consultant's identified discrepancies during random control drug audits for Resident #1, CR #3 and CR #4 even after an alleged case of drug diversion by LVN A over a three-month period. These failure could place residents at risk for misappropriation of medications and uncontrolled pain.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate and to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in process, and failed to ensure corrective action must be taken for 1 of 5 Residents (CR #1) reviewed for misappropriation of property. - The facility failed to thoroughly investigate allegations of misappropriation and ensure corrective actions were in place to ensure there was no further misappropriation of control substances after LVN A was identified for misappropriating CR #1's Tylenol #3 over a period of 3 months (June through August of 2023). This failures could place residents at risk of misappropriation of residents property

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 2 of 5 residents (Resident #2 and Resident #3) reviewed for pharmacy services in that: - The facility failed to enter orders as well as acquire and administer medications to Resident #2 as ordered immediately upon admission. - The facility failed to retrieve Resident #2's initial dose of medication from the facility emergency kit. - The facility failed to acquire and administer medications to Resident #3 as ordered immediately upon admission. These failures could place residents at risk of not receiving medications as ordered by their physician, inadequate disease management, uncontrolled pain, seizures, and serious harm.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from accidents for 1 of 12 residents (CR #2) reviewed for accidents hazards. - The facility failed to complete neurological checks per the facility policy when CR #2 had an unwitnessed fall on 11/24/23 after the initial 30 minutes following the fall. - The facility failed to complete neurological checks per the facility policy when CR #2 had an unwitnessed fall on 11/26/23 after the initial assessment until discharge to the hospital after a fall that resulted in head injury with brief loss of consciousness, small intra cranial bleed, hematoma, laceration and hospitalization. These failures could place residents at risk for unidentified changes in condition, decline in health and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs as identified through resident assessment and described in the plan of care and the facility failed to provide care which included but not limited to assessing, evaluating, planning and implementing resident care plans and responded to resident needs for 1 of 5 residents (Residents #2) and 1 of 3 nurses (RN D) reviewed for nurse competency. - The facility failed to ensure RN D was trained to admit residents and reconcile medications, prior to providing nursing services for Resident #2. This failure could place residents at risk of receiving inadequate care and harm.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 5 residents (CR #2) whose records were reviewed for resident identifiable records. - The facility failed to completely and accurately document interventions, assessments and neurological checks performed on CR #2 following falls on 11/24/23 and 11/26/23. This failure could place residents at risk of having incomplete or inaccurate records and inadequate care.

Inspectors wroteBased on interview and record review the facility failed to immediately inform resident's physician when a resident experienced increased shortness of breath for 1 of 1 resident (CR #1) reviewed for physician notification. LVN A failed to notify MD A in a timely manner on 8/5/23 when CR #1 was having increased shortness of breath. This caused a delay in CR #1 going to the hospital for to respiratory distress. RN A consulted with the NP but not the physician when CR#1 was having a change in condition An Immediate Jeopardy (IJ) situation was identified on 9/15/2023 9:10 am. While the IJ was removed on 09/19/2023 at 1:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 resident of 1 (CR #1) reviewed for quality of care. The facility failed to adequately assess and provide PRN respiratory treatments to CR #1 on 8/5/23 when he had increased shortness of breath, which led to respiratory distress and hospitalization. CR #1 was admitted to the hospital for shortness of breath. An Immediate Jeopardy (IJ) situation was identified on 9/15/2023 9:10 am. While the IJ was removed on 09/19/2023 at 1:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 1 nurse (LVN A) reviewed for nursing services. LVN A failed to have required documentation of competencies on change of condition. An Immediate Jeopardy (IJ) situation was identified on 9/15/2023 9:10 am. While the IJ was removed on 09/19/2023 at 1:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for inadequate or delayed treatment and interventions.

Inspectors wroteBased on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet resident's medical, nursing and mental and psychosocial needs which were identified in the comprehensive assessment for 1 of 5 residents(Resident #1) reviewed for care plans. -The facility failed to complete a comprehensive care plan that addressed the assessed needs and documented diagnoses for Resident #1 This failure could place residents at risk of not having their needs met, decreased quality of life or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 1 of 5 residents (Residents #1) for professional standards. - The facility failed to immediately transport Resident #1 to the hospital after the NP diagnosed the resident with a suspected pulmonary embolism( a blockage caused by a blood clot in the lungs). Resident #1 was sent by non-emergent transport over 2 hours after the order was given. This failure could place residents at risk of delay in treatment, adverse reactions and harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to make sure its medication error rate was not less than 5% of 2 of 25 residents reviewed for medication administration. 1. The facility's medication error rate was 8%. 2. The facility failed to order medications for medication administration at designated time. These deficient practices could place residents at risk of severe consequences leading to declining health, harm, or hospitalization due to missed medications.