Brightwater Skilled Nursing Center

In the surveyor’s words

From the most serious findings on record at Brightwater Skilled Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF886Jan 6, 2022

  Based on interview, review of facility policy and documentation, and review of Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance, the facility failed to ensure all staff working in the facility were tested and had documented results of COVID-19 status prior to working with residents. The facility's systemic failure of allowing staff with an unknown COVID-19 status to provide resident care increased the likelihood of transmission of COVID-19 which can lead to serious illness and death for all 47 residents residing in the facility. […]

• Immediate jeopardy, patternF880Jan 6, 2022

  Based on observations, interviews, record reviews, policy reviews, and review of the Centers for Disease Control and Prevention (CDC) Guidelines, the facility failed to have an effective Infection Prevention and Control Program (IPCP) to properly contain and prevent the transmission of COVID-19. The facility failed to: 1. Place Resident (R) 24, who was not fully vaccinated, on Transmission Based Precautions (TBP) for the required amount of time after testing positive for COVID-19. 2. Complete contact tracing for potentially exposed residents and staff after facility staff who were symptomatic of COVID-19 tested positive for COVID-19. 3. […]

• No harm, potential for more than minimal, widespreadF835Dec 2, 2025

  Based on review of the facility policy, observation, and interviews, the facility failed to have a full-time Administrator to oversee the day-to-day operations of the facility.Findings include:Review of the facility's policy titled Administrator, Policy Statement, revised March 2021, indicates:A licensed administrator is responsible for the day-to-day functions of the facility.The governing board of this facility has appointed an administrator who is duly licensed in accordance with federal and state requirements. The administrator is responsible for, but not limited to:a. Managing day-to-day functions of the facility. […]

• No harm, potential for more than minimal, widespreadF812Sep 13, 2023

  Based on observation, interview, and facility policy review, the facility failed to keep the kitchen's two convection ovens, stove top, two drawers and two plastic containers with food preparation and service equipment stored in them, and food preparation and service pans clean and/or dry. This failure had the potential to affect all 47 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Sanitation, dated 11/22, indicated, Policy Statement The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation . 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. 7. […]

• No harm, potential for more than minimal, widespreadF868Jan 6, 2022

  Based on interview, document review, review of the facility's policy, and review of the facility's Quality Assurance Performance Improvement (QAPI) program procedure, the facility failed to ensure the required members of the committee attended the QAPI meetings at least quarterly. The facility's Medical Directors did not attend any QAPI meetings for the four quarters of 2021. Findings include: During an interview and QAPI review on 01/06/22 at 7:05 PM, the Administrator confirmed the Medical Director had not attended any QAPI meetings for the year 2021. […]