Brighton Court Assisted Living.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A .

Statement of Deficiencies License #: 2629 Compliance Determination # 58002 Plan of Correction Brighton Court Assisted Living Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for the unannounced on-site full inspection on 04/08/2025, 04/09/2025, 04/10/2025, 04/11/2025 and 04/15/2025 of: Brighton Court Assisted Living 1308 N Vercler Rd Spokane Valley, WA 99216 The following sample was selected for review during the unannounced on-site visit: 9 of 42 current residents and 2 former residents. The department staff that inspected the Assisted Living Facility: Brian Zbylski, ALF Licensor Patricia Eddy, Community Licensor Tethra Wales, Assisted Living Facility Licensor From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 . From: To:6099212426 05/05/2026 13:06 #793 P.006 05.01.2025 12:33:09 state of Uashington 6/25 Si:~t~m➔nt •:}f Defo:1'0nde :s UcBnsB #: 2629 Cc-rnplia::-~oe Dete~m1n~t.ii:;n #b30D2 Plan -:;:f Co rr1:i:~.::ti t)n tLr~t~ht:o.:~ G,c,urt .::1.t,-s.isi0d L~~{lng C:a.rq~(ii1titn t.'latt:" Pag::· 2 ·Jf ·: S As J rt:suft of th~ :>n--s.te visit(s), ti·1,e dep-ai'trn~nt found U1zit ·yfS:J ari:; no~ in c~J-~T1pl~anc<:.'! ~\ilth- the ikt::-ns1n9 hlVVS and: r-:;·gulabG.t1S as st;1tr.~t~ in 'tht; (;.itt-d rji_?fic:.1erF;i'.~5 ff\ tht- enO-;lSf.:d n::pntt, 04/28/2025 ; ;Jtiderstan-- th.:~:t :·:.; rr~air~t&ln an A:ss~~te(i Li\"ing F ;;;::,iUt~/ ~ic.~r)~e; the : adht:l rrn.ist be-:1n ,:.:01r:ptanc2 1;·•-ht11 :al! the !kens1t:(~ la~-'vs and :·-~g:JL:it1ons at a_g ttne·s. WAC 388-78A-2210 Mt1d!cation services. (t;J O,:'.velDp and irnplerr-1-s-nt ~:l~iems J1£:t st1ppi:irt and protnotf..~ s~at-~ rn~:-:di-:ation .ser\..-i~:e far eBd·-1 r~si.dent. \2} The an.sisted llvin:;lfac.fty trn. .t st -::nsur1:i th:: fclkr:N~n~~ r~sidet~ts r~,:e1v{:: their rn~dicat;or:<; as pr-~s::.:·:'H;ed, f.X1 ~.ep-t :JS P:'~)Vided fr;r in \/'v'..L\C 3~S--78A--22JH ~ii'FJ J8rj .. '}'B,..~-•2:Jt\O (tq Enct1 p~_!sidentv,.•fl.J fP,;1~uires n:r:dk:atiar as:si53tanu~ and }ts ~1r h,:,;r ne:}:itiated ser>ii:::e· itQrt:,'}tne-nt mdk::Jtes the i1ss.1sted iiving fod~;ty- vA!§ pri:r. ., •·icie r1':ed~Gi:it~(~n a-csist::tnre; .a:1d This require;11<un1t wa;. not me;t as evldem::ed by: Bcs;sed nn intervievv anti re-~~~1rd re~gevv .. th~ f(::c:iiit~/ fcrH~ d to enr:ur~ ~ rmfe me{htJtHU! ti-e~f'.,erv sy·sti::rn vv: . i .. . : , . . : .. . 1 ' •·n~ ~ ) , ! _ r- . : r-r ~ -" - , - t: • . h if tte \_ d . aq I • '· ·t , h t ~ :. : , 1 . 1;:·· , , . l , : . . ~ _ : _ -. _ .. . V . ::n5: , ~ ._ ,t , · . e ' trl ) " ' •• C f - i - r ~ ' - ~ ·- t . ii , · ; : .. n ;, e ,. ; . ) , , , ver ,:: . '"d'f '"''t•½' t1 ·t"'L-.-:.~ .. : t r , , r,; ,. : _ . . , _ ., !: ~ -, . ~ ~ ,, i·i ., b e ' d f ,- A ..:, r , · .. 1 . ot ·1 ! ·1 , ~ , - . ~ .. , ~ ~ . · ! :- j~ - - · , ~ :i" - - " ,: ~ ' (R~~~dent 1 S antt ~?) This fr:!1:;:rt ri:~u~ttd 1n re-s1t:jn€ tt; n.::it rec.e,vin~J rnedic~t.ions as tJtf.scritied ~nd plJ<;ed re-S~iJt::nt-s ~t risk et f){;iJUb .t,0:rr~pi~cc·H~{1ns. R·f'vh::V\1 cJt f~r::siuent '~f~: Servk~e: PtH1 Ref;)ott nhe fw.:-;~it{s M]i::d ~'-i-1:~:Jotated Ser7.;·ice ,t,,;ir1:!ernent. l'I.JS.AJ: 1.1:atced D3.t1 Bh0·t,/2d that" f='<-t\sident g vv'::Js. i:?1J~lfE::se_j vvi2'1 and: ~\~rth~r rev:ev,.,, st~<)\>'\•~d that the resKier:t r:equirn·d rnettica6cn ai::.frninisrratori .. tht~t the f;sdt~ty ~·vGuld urdr::r, recei\.,e stGrt and &jr:·1tnisttr ail rni:-thcat~ons. ~1nrS that U:t r·r::s·ident \l\\iUld ! . Statement of Deficiencies License #: 2629 Compliance Determination # 58002 Plan of Correction Brighton Court Assisted Living Completion Date As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. Administrator (or Representative) Date WAC 388-78A-2210 Medication services. (1) An assisted living facility providing medication service, either directly or indirectly, must: (b) Develop and implement systems that support and promote safe medication service for each resident. (2) The assisted living facility must ensure the following residents receive their medications as prescribed, except as provided for in WAC 388-78A-2230 and 388-78A-2250 : (a) Each resident who requires medication assistance and his or her negotiated service agreement indicates the assisted living facility will provide medication assistance; and This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure a safe medication delivery system was implemented and failed to ensure medications were given as prescribed for 3 of 11 residents (Resident 2, 5 and 9). This failure resulted in residents not receiving medications as prescribed and placed residents at risk of health complications. Findings included... <Resident 9> Review of Resident 9’s Service Plan Report (the facility’s titled Negotiated Service Agreement, NSA), dated 03/14/2025, showed that Resident 9 was diagnosed with and . Further review showed that the resident required medication administration, that the facility would order, receive, store, and administer all medications, and that the resident would . Statement of Deficiencies License #: 2629 Compliance Determination # 58002 Plan of Correction Brighton Court Assisted Living Completion Date “be supported to take all medications safely and as ordered.” - Clopidogrel Bisulfate - Review of Resident 9’s January 2025 Medication Administration Record (MAR) showed a provider order for clopidogrel bisulfate tablet (a blood thinner to prevent heart attacks and strokes) to be given once a day. Further review showed that the medication was not administered from 01/02/2025 - 01/14/2025, with the exception of 01/09/2025 (resident was at the hospital) and 01/15/2025 (marked as administered). Review of Resident 9’s January 2025 Progress Notes showed the following: 01/02/2025 - [no information explaining why medication was not administered] 01/03/2025 -medication unavailable RCC [Residential Care Coordinator] working to resolve 01/04/2025 - 01/08/2025 - [no information explaining why medication was not administered] 01/10/2025 - out of medicine; pharmacy will be contacted 01/11/2025 - 01/13/2025 [no information explaining why medication was not administered] 01/14/2025 - staff has tried calling and staff has talked to [spouse] over the medication and they are going to call today 01/16/2025 - RCC working with pharmacy to get medication In an interview on 04/09/2025 at 1:50 PM, Staff I, Director of Health Services/RN, confirmed that Resident 9’s clopidogrel bisulfate tablet was not available from 01/02/2025 - 01/16/2025 (a total of 15 missed doses). Staff I further stated that the entry on 01/15/2025 that indicated the medication was administered was a transcription error and that the medication was not available to give to the resident on that date. In an interview on 04/11/2025 at 11:36 AM, Staff I confirmed that Resident 9’s provider was not notified that the resident had not received their medication. -Seroquel - Review of Resident 9’s December 2024 and January 2025 MARs showed a provider order for Seroquel (antipsychotic) twice daily, to treat the resident’s “psychosis and unsafe behaviors.” Further review showed it was not administered 12/06/2024 - 12/17/2024 and 01/01/2025 - 01/03/2025 but was marked as administered on 12/10/2024 (AM), 12/12/2024 (AM), 12/13/2024 (AM), 12/15/2024 (PM), and 12/16/2024 (AM). Review of Resident 9’s December 2024 and January 2025 Progress Notes showed the following: 12/06/2024 AM - pharmacy has not sent medication over yet 12/06/2024 PM - medication is yet to be delivered 12/07/2024 AM - RCC ordered and pharmacy has not delivered 12/07/2024 PM - med reorder, waiting for pharmacy to deliver 12/08/2024 AM - I called [facility pharmacy] and they said this is a VA issue 12/08/2024 PM - waiting for pharmacy to deliver, will call again tomorrow 12/09/2024 AM - out of medication .

Conclusion / Action: . Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Brighton Court Assisted Provider Type: Assisted Living Facility Living License/Cert.#: 2629 Intake ID: 151617 Compliance Determination #: 49500 Region/Unit #: RCS Region 1 / Unit B Investigator: Tethra Wales Investigation Date(s): 10/29/2024 through 10/31/2024 Complainant Contact Date(s): Allegation(s): Staff was inappropriately hugging a resident Investigation Methods: Sample: Total residents: 40 Resident sample size: 6 Closed records sample size: 0 Observations: Staff presence and availability Staff and resident interactions Lighting and line of sight in common areas and hallways Interviews: Caregivers Med Techs Alleged victim Residents Administrator Record Reviews: Characteristic roster Staff roster Resident face sheets Resident care plans Incident Report and Investigation Progress notes Staff background checks Investigation Summary: The facility investigated the incident, provided for safety, and the alleged perpetrator was terminated. During the course of the investigation a background check was identified as requiring a review of a staff member's record. The facility had not completed a character, competence, and suitability review for one sampled staff. Failed practice identified and cited under WAC 388-78A-24701(1). Conclusion / Action: . Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2629 Compliance Determination # 49500 Plan of Correction Brighton Court Assisted Living Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 10/29/2024 and 10/29/2024 of: Brighton Court Assisted Living 1308 N Vercler Rd Spokane Valley, WA 99216 This document references the following complaint number(s): 152301, 151617 The following sample was selected for review during the unannounced on-site visit: 6 of 40 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Tethra Wales, Assisted Living Facility Licensor From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. . . Statement of Deficiencies License #: 2629 Compliance Determination # 49500 Plan of Correction Brighton Court Assisted Living Completion Date Administrator (or Representative) Date WAC 388-78A-24701 Background checks Employment Nondisqualifying information. (1) If the background check results show that an employee or prospective employee has a criminal conviction or pending charge for a crime that is not a disqualifying crime under chapter 388-113 WAC, then the assisted living facility must determine whether the person has the character, competence and suitability to work with vulnerable adults in long-term care. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete a character, competence and suitability review for 1 of 4 staff (Staff B) who had a non-disqualifying crime. This failure placed residents at risk of receiving services from staff members who were not evaluated for character, competence, and suitability to work with vulnerable adults. Findings included… Review of Staff B’s, Housekeeper, name and date of birth background check, completed on 09/17/2024, showed that it required review of a non-disqualifying criminal conviction. Review of Staff B’s record showed no character, competence, and suitability (CCS) had been completed. In an interview on 10/31/2024 at 2:25 PM, Staff A, Administrator, stated that a CCS review was not completed for Staff B. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Brighton Court Assisted Living is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. . . Statement of Deficiencies License #: 2629 Compliance Determination # 49500 Plan of Correction Brighton Court Assisted Living Completion Date Administrator (or Representative) Date .

findings did not support violations. No failed facility practices were found related to allegation. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . 08.05.2024 14:02:50 State of Washington 4/9 STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTF~ATION 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement. o f Deflcie11cies ... Ucense #: 2e29 com1iiiance· beformination·#·44092 Plan of Correction Brighton Cou11 Assisted Living Completion Date You are required to be in compliance at all times with all licensing laws and regL1lations to maintain your Assisted Living Facility license. The department completed data collection tor an Llnannounced on-site complaint investigation on 07/12/2024, 07/12/2024 and 07/12/2024 of: Brighton Court Assisted Living 1308 N Vercler Rd Spokane Valley, WA 99216 This document references the following complaint nurnber(s): 137021 The following sample was selected for review during the unannounced on-site visit: 9 of 38 CLirrent residents and o former residents. The department staff that investigated the Assisted Living Facility: RECEIVED Sylvia Shauvin, Complaint Investigator AUG O9 2024 OSHS ALTSA RCS From: DSHS, Aging and Long-Term Support Administration SPOKANE VALLEY v,;,'\ 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. 08/05/2024 I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. . 08.05.2024 14:02:50 State of Washington 5/9 Statement of Deficiencies License #: 2629 Compliance Determination # 44092 Plan of Correction Brighton Court Assisted Living Completion Date Administrator (or Representative) Date WAC 388-78A-2140 Negotiated service agreement contents. The assisted living facility must develop, and document in the resident's record, the agreed upon plan to address and support each resident's assessed capabilities, needs and preferences, including the following: (1) The care and services necessary to meet the resident's needs, including: (a) The plan to monitor the resident and address interventions for current risks to tl,e resident's health and safety that were identified in one or more of the following: (iii) On-going assessments of the resident; (b) The plan to provide assistance with activities of daily living, if provided by the assisted living facility; (2) Clearly defined respective roles and responsibilities of the resident, the assisted living facility staff, and resident's family or other significant persons in meeting the resident's needs and preferences. Except as specified in WAC 388-78A-2290 and 388-78A-2340 (5), if a person other than a caregiver is to be responsible for providing care or services to the resident in the assisted living facility, the assisted living facility must specify in the negotiated service agreement an alternate plan for providing care or service to the resident in the event the necessary services are not provided. The assisted living facility may develop an alternate plan: (a) Exclusively for the individual resident; or This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to include instructions in the negotiated service agreement related to a resident's food and fluid intake for 1 of 3 residents (Resident 3) who received hospice services. This failure placed the resident at risk for inconsistent feeding assistance and at risk for aspiration of food/fluids into their lungs. Findings included ... Review of the undated Face Sheet for Resident 3 showed they had diagnoses including , , , and . In an interview on 07/03/2024 at 10:10 AM, Collateral Contact 1 (CC1), family member of Resident 3, stated the resident had a stroke that affected the resident's ability to use the right side of their body. CC1 stated Resident 3 was unable to independently use utensils to eat and needed to be fed. CC1 further stated they were concerned that the . 08.05.2024 14:02:50 State of Washington Statement of Deficiencies License #: 2629 Compliance Determination # 44092 Plan of Correction Brighton Court Assisted Living Completion Date facility wasn't providing the resident with enough encouragement and help to eat, and the facility didn't provide the family with a current care plan that included staff's interventions related to Resident 3's nutritional intake. In an interview on 07/03/2024 at 1O : 1O AM Collateral Contact 2 (CC2), family member of Resident 3, stated Resident 3 was sometimes able to verbalize they were thirsty and hungry. CC2 stated the facility didn't provide the resident with help to eat and provided minimal amounts of fluids. Observations on 07/12/2024 at 10:08 AM, showed Resident 3 was in bed, asleep. Staff A, Medication Aide/Caregiver was observed waking the resident and providing them with the resident's medication. Staff A provided the medication in applesauce, which Resident 3 accepted. Collateral Contact 3 (CC3), family member of Resident 3 was observed at the resident's bedside. In an interview on 07/12/2024 at 10:08 AM, CC3 stated Resident 3 was hospitalized on /2024 for urinary tract infection and hallucinations. CC3 stated the resident was diagnosed at the hospital with , received rehabilitation services, and at the time was able to independently use utensils and eat. CC3 stated Resident 3 returned to the facility on /2024. CC3 stated the resident's physical function declined after returning to the facility and the resident was placed on hospice services on 07/02/2024. CC3 further stated that llospice staff and Staff B. Director of Nursing, believed Resident 3 should not be fed. CC3 stated they disagreed witl1 this, and they frequently visited Resident 3 and fed the resident applesauce, small amounts of fruit, and Cream of Wheat. They stated the resident ate scrambled eggs that morning. CC3 stated they themselves or the facility provided food for the resident. When the department investigator asked CC3 what the facility and resident/family negotiated related to the resident's food/fluid intake, CC3 could not specify. In an interview on 07/12/2024 at 12:10 PM, Staff C, Caregiver, stated Resident 3 currently took meals in their apartment. Regarding the staff's responsibility related to Resident 3's meals, Staff C stated staff should check on and remind the resident to eat, in case the resident fell asleep. Staff C also stated Resident 3 had problems with swallowing. In an interview on 07/23/2024 at 11:15 AM, Staff A stated Resident 3 required assistance with feeding. Staff A stated the resident's acceptance of medications and food varied, and staff did not force the resident to take them. Staff A was unsure about how facility staff received instructions about Resident 3's food and fluid needs. In an interview on 07/23/2024 at 11 :40 AM. CC3 stated they gave Resident 3 some Cream of Wheat and sips of water. CC3 stated they sometimes brought foods, such as chili for Resident 3 to have at lunch. CC3 stated staff were currently offering the resident food at times, adding that the resident sometimes eagerly accepted the food and at other times did not because the resident was unable to exercise the thought process to eat. CC3 stated the facility provided the family with an updated negotiated . 08.05.2024 14:02:50 :5tate or wash! ngton Statement of Deficiencies License #: 2629 Compliance Determination # 44092 Plan of Correction Brighton Court Assisted Living Completion Date Page4 ofS Licensee: Sapphire at Brighton Court LLC 07/29/2024 service agreement (NSA). The department investigator asked CC3 to provide the department investigator with a copy of the NSA they received from the facility. In an interview on 07/23/2024 at 11 :40 AM, CC4, Resident 3's family member stated the resident sometimes eagerly accepted their favorite foods, such as ice cream with chocolate sauce, CC4 stated Staff B did not provide verbal or written details to the family related to Resident 3's food and fluid needs. CC4 stated, "We're not expecting (facility) to force feed (Resident 3), but they should provide information about what to do when (Resident 3) wants/is willing to take food and fluids." In an interview on 07/23/2024 at 1 :23 PM, CC5, Hospice Nurse, stated hospital staff initiated a request for hospice services for Resident 3, which were started on 07/02/2024. CC5 stated Resident 3 experienced a change in nutritional needs and decreased intake after returning to the facility from the hospital.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 8517 E Trent Ave, Ste 102, Spokane Valley, WA 99212 Statement of Deficiencies License #: 2629 Compliance Determination # 40853 Plan of Correction Brighton Court Assisted Living Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 05/06/2024 and 05/06/2024 of: Brighton Court Assisted Living 1308 N Vercler Rd Spokane Valley, WA 99216 This document references the following complaint number(s): 126479 The following sample was selected for review during the unannounced on-site visit: 5 of 43 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Sandra Fast, Community Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 8517 E Trent Ave, Ste 102 Spokane Valley, WA 99212 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. . . Statement of Deficiencies License #: 2629 Compliance Determination # 40853 Plan of Correction Brighton Court Assisted Living Completion Date Administrator (or Representative) Date WAC 388-78A-2320 Intermittent nursing services systems. (1) When an assisted living facility provides intermittent nursing services to any resident, either directly or indirectly, the assisted living facility must: (a) Develop and implement systems that support and promote the safe practice of nursing for each resident; and (b) Ensure the requirements of chapters 18.79 RCW and 246-840 WAC are met. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to ensure nurse delegation criteria was followed and failed to ensure staff were credentialed and qualified to provide nurse delegated services for 1of 1 staff (Staff C). This failure placed residents at risk of unsafe medication administration from caregivers who were not trained, delegated, registered, or certified to perform nurse delegated tasks. Findings included… Per WAC 246-840-930, Criteria for delegation - Verify that the nursing assistant or home care aid: - Is currently registered or certified as a nursing assistant or home care aid in Washington state without restriction. - Has completed both the basic caregiver training and core delegation training before performing any delegated task. - Has evidence as required by the department of social and health services of successful completion of nurse delegation core training and special focus diabetes training when providing insulin injections to a diabetic client. Review of Resident 1’s medication administration record (MAR) showed Staff C, Medication Technician, performed blood sugar checks (measures the level of sugar in the blood) and insulin administration (an injectable medication that regulates the level of sugar in the blood) for Resident 1 on 04/21/2024, 04/22/2024, 04/28/2024, 04/29/2024, and . . Statement of Deficiencies License #: 2629 Compliance Determination # 40853 Plan of Correction Brighton Court Assisted Living Completion Date 05/06/2024. In an email communication on 05/06/2024, at 10:26 AM, Staff B, Business Office Manager wrote that the facility was just made aware that Staff C was not nurse delegated and did not have core or diabetes delegation trainings (as required). In an interview on 05/06/2024, at 10:30 AM, Staff B stated that Staff C had accidentally been placed on the schedule as a Medication Technician without the appropriate certification or training. A record review of personnel documents for Staff C, Medication Technician, showed that Staff C was not registered or credentialed and had not completed the required approved educations for nurse delegation basic and special focus diabetes training. The personnel records also lacked proof of Staff C being checked off for delegated tasks by the registered nurse delegator. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Brighton Court Assisted Living is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date .

findings support failed facility practice - 388-78A-2464 (2) (Submit to the department's background check central unit, including any additional documentation and information requested by the department.) Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . . . .