Khadi Care Center LLC

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two personnel sampled. 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)..." A review of the Centers for Disease Control and Prevention website revealed a web page, located at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm, titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." This guideline states: "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." A review of the Centers for Disease Control and Prevention website revealed a web page, located at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm, titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." This guideline states: Baseline Testing for M. tuberculosis Infection After TST Within the Previous 12 Months: "A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST result within the previous 12 months, a single TST can be administered in the new setting (Box 1). This additional TST represents the second stage of two-step testing. The second test decreases the possibility that boosting on later testing will lead to incorrect suspicion of transmission of M. tuberculosis in the setting." A review of the Centers for Disease Control and Prevention website revealed a web page, located at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm, titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." This guideline states: Findings include

Based on documentation review, observation, and interview, the governing authority failed to designate a currently licensed manager in writing. The deficient practice posed a risk as the assisted living facility did not have a licensed manager for approximately 80 days. Findings include: 1. A review of Department documentation revealed an application submitted October 5, 2024, designating E1 as the manager of the facility. 2. The Compliance Officer observed E1's managers license posted in the facility. 3 . Online verification of E1's manager's license at https://aznciab.portalus.thentiacloud.net/webs/portal/#/ revealed E1's license had expired on January 31, 2025. 4. In an interview, E1 reported being unaware that E1's managers license had expired and thinking licenses expired in June every other year. E1 reported E1 would contact the Arizona Nursing Care Institution Administrators and Assisted Living Facility Managers board immediately and if E1's license had expired, E1 would immediately designate another manager. 5. A review of department records revealed E1 notified the Department on April 22, 2025, the day of the on-site inspection, of the appointment of a new manager, E3.

Based on record review and interview, the manager failed to ensure, for one of two sampled residents, a residency agreement was signed and dated by the manager before or at the time of a resident's acceptance by the assisted living facility. Findings include: A review of R1's medical record revealed a residency agreement which was signed and dated by the governing authority. However, the governing authority had signed the residency agreement twelve days after R1's time of acceptance. In an interview, E1 acknowledged R1's residency agreement had not been signed before or at the time of R1's time of acceptance.