Tulsi Assisted Living, LLC.

“Based on documentation review, observation, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411 for three of the three personnel sampled. The deficient practice posed a risk if E1, E2, and E3 were a danger to a vulnerable population. Findings include:  1. A.R.S. § 36-411(C)(4) states, “On or before March 31,2025, verify that each employee is not on the adult protective services registry (APS) pursuant to section 46-459…” 2. While on-site for the compliance inspection, the Compliance Officers observed E2 and E3 at the facility, providing services to residents.   3. A review of E1's, E2’s, and E3's personnel records revealed no documentation check of the adult protective services registry. 4. A review of the adult protective services registry revealed that E1, E2, and E3 were not on the registry.   5. In an interview, E1 acknowledged that the facility did not verify that E1, E2, and E3 were not on the adult protective services registry.”

“Based on documentation review and interview, the manager failed to implement an ongoing quality management program, which included a method to evaluate the data collected to identify concerns about the delivery of services related to resident care and the submission of reports to the governing authority.   Findings include:   1. A review of the facility's policies and procedures revealed a quality management policy titled “Quality Management Program.” The policy stated. “The manager or manager’s designee shall ensure that a method to identify, document, and evaluate incidents is established, documented, and implemented.” 2. A review of the facility’s quality management documentation revealed a report dated April 4, 2020. However, documentation of additional reports was not available for review.   3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on the record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, which was completed no later than 14 calendar days after the resident's date of acceptance, for one of two residents sampled. Findings include: 1 . A review of R2's medical record revealed that documentation of a completed service plan was not available for review at the time of inspection. Based on R2's date of acceptance, a service plan was required. 2 . In an interview, E1 reported that E1 had completed R2's service plan but doesn't remember where E1 put it. 3 . In an exit interview, the findings were reported to E1, and no additional information was added.”

“Based on the record review and interview, the manager failed to ensure a written service plan was updated at least once every three months for one of one residents reviewed who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed.   Findings include:   1.    A review of R1's medical record revealed a current written service plan for directed care services dated November 25, 2024. However, a service plan after November 25, 2024, was not available for review.   2.     In an interview, E1 reported that E1 had completed R1's service plan but doesn't remember where E1 put it.     3.    In an exit interview, the findings were reported to E1, and no additional information was added.”