Sun Health Assisted Living at the Colonnade

Based on documentation review, record review, and interview, the manager failed to ensure a manager provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for two of four sampled employees. The deficient practice posed a potential 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E1's (hired in April 2024) personnel record revealed one TB skin test done on E1's hire date and one after the hire date. 4. A review of E2's (hired in May 2024) personnel record revealed one TB skin test done after the hire date. No additional documentation of freedom from infectious TB was available for review including the initial assessment. 5. In an interview, E1 acknowledged E1 and E2 did not provide documentation of freedom from infectious TB as specified in R9-10-113. Technical assistance was provided on this Rule during the compliance inspection conducted March 29-30, 2023.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed ambulatory residents. 2. During the environmental inspection, the Compliance Officer observed a large container of bleach (5.32 L) in the unlocked laundry room that was accessible to the residents. 3. During the environmental inspection, the Compliance Officer observed the following chemicals in an unlocked activities room that was accessible to the residents: - Gorilla Hot Glue Sticks - A spray bottle of Lysol All Purpose Cleaner - A spray bottle of Stem. - A bottle of Gorilla Wood Glue 4. In an interview, E1 acknowledged that toxic materials were not stored in a locked area and inaccessible to residents.

Based on observation and interview, the manager failed to ensure combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. The Compliance Officer observed ambulatory residents. 2. During the environmental inspection, the Compliance Officer observed an unlocked door which led to a salon located in the memory care wing of the building. The following chemicals had a flammable warning label and were found in the unlocked room: - A spray canister of Cool Care Plus for Clipper Blades - A spray canister of Bed Head - Two spray canisters of Joimist Medium Protective Finishing Spray 3. During the environmental inspection, the Compliance Officer observed a spray can of Mod Podge Super Hi-Shine in an unlocked activities room that was assessable to residents. This spray can had a flammable warning label. 4. In an interview, E1 acknowledged flammable liquids and hazardous materials stored by the facility were not stored in a locked area inaccessible to residents.