Sanctuary I Assisted Living.

“Based on documentation review and interview, the health care institution’s chief administrative officer failed to implement tuberculosis (TB) infection control activities that annually assessed the health care institution’s risk of exposure to infectious tuberculosis. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of the facility's documentation revealed no documentation that annually assessed the facility’s risk of exposure to tuberculosis. 2. In an interview, E1 acknowledged that an assessment of the facility's risk of exposure to tuberculosis was not conducted. 3. In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed a disaster plan for the facility; however, no documentation of previous and current annual reviews was available at the time of the inspection. 2. In an interview, E1 acknowledged that an annual disaster plan review was not conducted. 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan that accurately reflected the amount, type, and frequency of assisted living services being provided, for one of two sampled residents. The deficient practice posed a health and safety risk to a resident should services not be provided as required to meet the residents' needs. Findings include: 1. A review of R1's medical record revealed a service plan dated August 30, 2024. R1's service plan indicated R1 required assistance with Shower, Complete bath 2x a week/PRN (as needed) and Wash hair, Peri care - Daily & PRN. 2. A review of R1's Activities of Daily Living log dated September 2024 did not include documentation assistance was provided with showers, baths, washing hair, and peri care. 3. In a joint interview, E1 and E2 stated R1 was independent and did not need assistance with showers, baths, washing hair, and peri care. E1 and E2 acknowledge the service plan did not accurately reflect the amount, type, and frequency of service provided to R1.”