Gardens Care Senior Living Scottsdale

Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A.R.S. § 46-454(A) states: "A health professional... or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the vulnerable adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...The reports required by this subsection shall be made immediately by telephone or online." 2. Arizona Administrative Code (A.A.C.) R9-10-101(111) states, "'Immediate' means without delay." 3. A review of facility documentation revealed an incident report regarding abuse, neglect, and exploitation reported to adult protective services (APS). The report stated: "On September 29, 2025 around 7:45 pm ... MC resident had a reported fall. It was communicated to community nurse that the resident urinated on the floor, slipped no injuries. After investigating that was not the case. Resident pulled down pants, urinated, and ... [E2] did not urgently assist even though [E2] was in the room. After a caregiver came, the resident was left half naked with pants around [R1] ankles and while trying to remove them fell backwards hitting [R1] head. [E2] was in the same room and did not urgently try to help, called for a caregiver and went back to [E2] computer. The Resident was left on the floor half naked unattended while [E2] was in the room and at one point even left ..." However, APS was notified on October 02, 2025. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for five of seven employees sampled (employees who had or were expected to have more than eight hours of direct interaction with residents). 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. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E2's personnel records revealed a negative TB skin test that was less than 12 months old; however, no documentation of a second negative TB skin test was available for review. Based on E2's hire dates, this documentation was required. 4. A review of E2’s personnel record showed documentation of assessing the risk of prior exposure to infectious TB and determining whether E2 had any signs or symptoms of TB; however, the documentation was not signed by a registered nurse, medical practitioner, or local health department. Based on E2’s hire date, this documentation was required. 5. A review of E5's personnel records revealed a negative TB skin test that was less than 12 months old; however, no documentation of a second negative TB skin test was available for review. Based on E5's hire date, this documentation was required. 6. A review of E5’s personnel record showed documentation of assessing the risk of prior exposure to infectious TB and determining whether E5 had any signs or symptoms of TB; however, this documentation was completed after the date the individual began prov

Based on record review, documentation review, and interview, the manager failed to ensure that a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training for one of seven employees sampled. The deficient practice posed a risk if an employee was unable to meet the needs of residents. Findings include: 1. A review of E8’s personnel record revealed that E8 worked as a caregiver and had a “Recognition of Completion” certificate stating they had successfully completed HSI online training for “HSI Adult First Aid | CPR AED Adult (2020) – (Blended)-DC,” with a completion date of 09/24/2024. However, the documentation also stated that blended learning included computer-based lessons plus hands-on skill practice and a performance evaluation by an HSI instructor, and the certificate only verified completion of the online portion; documentation of the required hands-on CPR demonstration was missing. Based on E8’s hire date, this documentation was required. 2. A review of personnel schedules revealed that E8 had been working as a caregiver and provided assisted living services to residents. 3. In an interview, E1 reported that all staff were required to have current CPR and First Aid certification completed before providing assisted living services to residents. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a resident rights violation if the resident was subjected to abuse. Findings include: 1. A review of facility documentation revealed an incident report regarding abuse, neglect, and exploitation reported to adult protective services (APS). The report stated: "On September 29, 2025 around 7:45 pm ... MC resident had a reported fall. It was communicated to community nurse that the resident urinated on the floor, slipped no injuries. After investigating that was not the case. Resident pulled down pants, urinated, and ... [E2] did not urgently assist even though [E2] was in the room. After a caregiver came, the resident was left half naked with pants around [R1] ankles and while trying to remove them fell backwards hitting [R1] head. [E2] was in the same room and did not urgently try to help, called for a caregiver and went back to [E2] computer. The Resident was left on the floor half naked unattended while [E2] was in the room and at one point even left ..." However, APS was notified on October 02, 2025. 2. In an interview, E1 acknowledged R1 was not treated with dignity, respect, and consideration. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for one of three resident sampled. Findings include: 1 . A review of R1's medical record revealed a "Task Administration Record." The "Task Administration Record" included the following services: -Oral Care-Partial Assistance; -Toileting-Full Assistance; and -Dressing-Full Assistance. However, the services were not documented as administered on the following dates: -Oral Care (PM) on September 3, 2025 and September 21, 2025; -Toileting (AM) on September 22, 2025; Toileting (PM) on September 3, 2025 and September 21, 2025; -Toileting (NOC) on September 3, 2025; September 4, 2025; September 18, 2025; and September 22, 2025; and -Dressing (PM) on September 3, 2025 and September 21, 2025. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to the physical health and safety of a resident. Findings Include: 1. A review of facility documentation revealed an incident report regarding R2 dated July 2, 2025. The incident report stated “Resident stated had a fall during night, pressed pendant no assistance provided by CG. Resident lifted [self] from the floor and went to her bed, resident stated they hit their right shoulder area on counter. “ 2. In an interview, E1 reported that when the day staff came into the facility on July 02, 2025, the staff ran a report of all the calls from the pendants from the residents. When the staff was reviewing the call report, they noticed that several calls had gone unanswered. E1 reported there were two caregivers on staff for the night shift, who were E4 and E6. The first caregiver, E4 on the night staff, reported that they had not answered the call from the resident due to the walkie-talkie not being charged, and the second caregiver reported they had not been given a walkie-talkie. 3. In an interview, E1 reported that both night caregivers were suspended and taken off the schedule immediately for further investigation. E1 acknowledged E4 and E6 had put the health, safety, or welfare of residents at risk of harm.

Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk of injury and violated a resident's rights. Findings Include: 1. A review of facility documentation revealed an incident report for R2 dated July 2, 2025. The incident report stated “Resident stated had a fall during night, pressed pendant no assistance provided by CG. Resident lifted [self] from the floor and went to her bed, resident stated they hit their right shoulder area on counter. “ 2. In an interview, E1 reported that when the day staff came into the facility on July 02, 2025, the staff ran a report of all the calls from the pendants from the residents. When the staff was reviewing the call report, they noticed that several calls had gone unanswered. E1 reported there were two caregivers on staff for the night shift, who were E4 and E6. The first caregiver, E4 on the night staff, reported that they had not answered the call from the resident due to the walkie-talkie not being charged, and the second caregiver reported they had not been given a walkie-talkie. 3. In an interview, E1 reported that both night caregivers were suspended and taken off the schedule immediately for further investigation. E1 acknowledged that E4 and E6 had not treated the residents with dignity, respect, and consideration.