The Commons at Brightmore

The facility failed to ensure health care referral and follow-up to meet the health care needs for Resident #3. Specifically, the facility did not document that the resident's Primary Care Provider was notified when the resident refused Lamotrigine on multiple dates in March and April 2022.

The facility failed to ensure proper health care referral and follow-up for a resident who refused medications for hypertension and cognitive disorders. Specifically, there was no documentation that the resident's Primary Care Provider was notified of medication refusals for Lamotrigine on multiple dates in March and April 2022.

The facility failed to ensure that 3 of 12 sampled staff members were tested for tuberculosis in compliance with required control measures. Specifically, personnel records for Staff B and Staff C lacked documentation of a 2-step TB skin test upon hire.

The facility failed to ensure that 3 out of 12 sampled staff members (Staff B, C, and D) were tested for tuberculosis in compliance with required control measures. Personnel records for these employees lacked documentation of the required 2-step TB skin tests upon hire.

The facility failed to implement proper infection control measures during medication administration. Specifically, a Medication Aide was observed administering oral and eye medications to multiple residents without washing hands, using hand sanitizer, or wearing gloves.

The facility failed to implement proper infection control measures during medication administration. A Medication Aide was observed administering oral medications and eye drops to multiple residents without washing hands, using hand sanitizer, or wearing gloves, creating a risk of cross-contamination.

The facility failed to provide supervision in accordance with residents' assessed needs, care plans, and current symptoms for two residents. Specifically, for Resident #5, the facility failed to complete required fall assessments following multiple falls, including an incident that required an emergency room visit.

The facility failed to provide supervision in accordance with residents' assessed needs, care plans, and current symptoms for two residents. Specifically, Resident #5 experienced multiple falls, including a fall that resulted in a C6 fracture and death, with several instances where no fall assessment was completed following incidents.