Ashton Gardens Assisted Living LLC

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB. Based on R2's date of acceptance, this documentation was required. 3. A review of R3's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB. Based on R3's date of acceptance, this documentation was required. 4. In an interview, E1 acknowledged R2's and R3's medical records did not include documentation of a risk assessment of prior exposure to infectious TB. Technical assistance was provided on this Rule during the inspection conducted on February 6, 2024.

Based on record review and interview, the manager failed to ensure a service plan included cognitive stimulation and activities to maximize functioning; strategies to ensure residents personal safety; encouragement to eat meals and snacks; and coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan, for two of two resident sampled who received directed care services. Findings include: 1. A review of R1's medical record revealed a service plan dated in November 2023. However, the service plan did not include cognitive stimulation and activities to maximize functioning, strategies to ensure R1's personal safety, encouragement to eat meals and snacks, and coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan. 2. A review of R3's medical record revealed a service plan dated in December 2023. However, the service plan did not include cognitive stimulation and activities to maximize functioning, strategies to ensure R3's personal safety, and coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan. 3. In an interview, E3 acknowledged R1's and R3's service plan did not include the above mentioned requirements.