Gardenia Adult Care Home, LLC

Based on observation and interview, the governing authority failed to designate, in writing, a manager who either had a certificate as an assisted living facility manager issued under Arizona Revised Statutes (A.R.S.) § 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. During a documentation review, the Compliance Officer observed E2 was appointed manager and began working for the facility on August 30, 2025. 2. A review of the Arizona Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA) Board revealed E1’s manager’s license expired on April 10, 2025. 3. In an interview, E1 acknowledged E1’s manager’s license expired on April 10, 2025. E1 and E3 further reported forgetting about the change of renewal dates in the last few years. 4. E1 acknowledged the facility did not have a licensed manager from April 10, 2025 until August 30, 2025.

Based on record review, documentation review, and interview, the manager failed to ensure that a personnel record for each employee included documentation of compliance with the requirements in A.R.S. § 36-411(C), for two of three personnel records reviewed. The deficient practice posed a risk if an employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411.C(3-5) states: "C. Owners shall make documented, good faith efforts to: 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459." 2. A review of E1’s and E3’s personnel records revealed an APS Central Registry check was not available for review. 3. An online review of the Arizona Department of Public Safety (DPS) web portal, at https://psp.azdps.gov/services/cardStatusRequest, revealed that E1 and E3 were not on the APS Central registry. 4. In an interview, E1 acknowledged that the manager failed to ensure that a personnel record for each employee included documentation of compliance with the requirements in A.R.S. § 36-411(C).

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a direct health and safety risk to residents. Findings include: 1. The Compliance Officer observed the backyard, accessible to residents, to have a wooden fence surrounding the backyard. The Compliance Officer observed some slats from the fence that were splitting apart and a section of the fence was leaning outward and had an open section covered with a sheet. 2. In an interview, E1 acknowledged the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury. E1 reported sections of the fence were being quoted for repair or replacement.

Based on record review and interview, the health care institution's chief administrative officer failed to ensure an individual, for whom baseline screening and documentation of freedom from infectious tuberculosis (TB) was required, obtained as evidence of freedom from TB: c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. That the individual was free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R9-6-101. Findings include: 1. A review of R1's medical record revealed documentation of a positive QuantiFERON TB Gold Plus Test collected on November 10, 2022. The documentation revealed the Medical Practitioner reviewed the test on November 13, 2022 and recommended to repeat the QuantiFERON TB Gold Plus Test, a sputum gram stain and culture, and a CT scan without contrast. 2. R1's medical record revealed a repeated positive QuantiFERON TB Gold Plus Test collected on November 15, 2022. The Medical Practitioner reviewed the results on November 17, 2022 and noted, "TB testing still positive. Await Sputum Gram stain and CT of Chest. Would now recommend PULM CONSULTATION with [O1] and associates ASAP > OK to see FNP first." 3. R1's medical record revealed the Sputum Gram stain result documentation was negative and reviewed by the Medical Practitioner on November 19, 2022. The medical Practitioner noted, "Sputum gram stain did not show any acid-fast bacilli. So far is only normal flora. Would still recommend seeing pulmonary [O1] or associates. Please see CT scan of the chest repeated 11/2022". 4. Further review of R1's medical record revealed the results of a Chest CT without contrast, performed on November 15, 2022. The Medical Practitioner reviewed the results and noted, " ...recommend consultation with [O1] or associates ASAP. May need Bronchoscopy due to positive Quantiferon and ABN CT of chest DX pulmonary fibrosis". 5. In an interview, E1 reported R1 did see the pulmonologist and R1's family member accompanied R1 to the appointment. E1 phoned R1's primary care provider's office and was advised no other documentation was received from the pulmonology office and the notes from the pulmonologist do not discuss TB. 6. In an interview E1 acknowledged the health care institution failed to obtain as evidence of freedom from TB, if an individual had a positive tuberculosis screening test, a written statement that the individual was free from infectious tuberculosis, signed by a medical practitioner or local health agency for R1.