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.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of facility policies and procedures revealed no documentation to indicate a fall prevention and fall recovery training program was developed. 2. A review of facility documentation revealed personnel records for E1, E2, E3, E4, and E5 were not available for review. No documentation of initial training and continued competency training in fall prevention and fall recovery for any facility staff was available for review. 3. In an interview, E1 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery. E1 reported E1 was not familiar with the statute.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked. Findings include: 1. The Compliance Officer arrived at AL10418 at 10:00 AM and was greeted at the door by E3. The Compliance Officer observed four residents on the premises. The Compliance Officer observed E3, E4, and E5 all working on the premises during the course of the inspection. The Compliance Officer observed caregiver certificates for E3 and E4 were posted on the facility's kitchen wall. The Compliance Officer observed E1 arrived at the facility at approximately 12:20 PM. 2. A review of facility documentation revealed staffing schedules indicating caregivers scheduled to work in July and August, 2023. However, the schedules did not include documentation of hours worked by caregivers each day. 3. In an interview, E3 reported E3 and E4 were hired at the facility as certified caregivers. E3 reported E4 was working on site at the facility every day. E3 reported E5 was "just a friend" who sometimes came by to cook and visit with residents. 4. In an interview, E1 reported the facility usually maintains two shifts, from 7:00 AM to 7:00 PM (Day) and from 7:00 PM to 7:00 AM (Night). E1 reported E3 and E4 were caregivers who usually worked the day shifts, and E1 and E2 were both certified assisted living managers who usually worked the night shifts. E1 reported E5 was a "volunteer" who was "still being trained" and did not work set hours. E1 acknowledged the hours worked by E1, E2, E3, and E4 were not on the schedules, and the facility did not maintain documentation of the hours worked by caregivers each day.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record was established and maintained for each employee, for five of five personnel members sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the personnel record did not include the documentation during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of facility policies and procedures revealed a policy titled, "Personnel Records" which stated, "Personnel records are maintained on every employee and are the property of the facility...1. A personnel record for each employee or volunteer shall be maintained at the facility. 2. The manager shall ensure that comprehensive personnel records are maintained for all employees in order to document their employment history with the facility..." 2. A review of facility documentation revealed no personnel records for E1, E2, E3, E4, or E5 were available for review. 3. In an interview, E3 reported E3 and E4 were hired at the facility as certified caregivers. E3 reported E5 was "just a friend" who sometimes came to the facility to cook and visit with residents. E3 reported E3 was unsure where facility personnel records were maintained and asked E1 and E2 for assistance in providing the Compliance Officer with records. 4. In separate interviews with alert and oriented residents, R1 and R4 both reported R1 and R4 received assisted living services from E5. R4 reported E5 had worked at the facility for "about half a year" and "was the best cook on staff." R4 reported E5 frequently visited with R4 alone and put medication on R4's legs. 5. In an interview, E1 reported E1 was the facility's owner and worked at the facility as a caregiver. E1 confirmed E2 was the facility's manager and also worked on site as a caregiver. E1 reported E3 and E4 were both facility caregivers. E1 reported E5 was a "volunteer" at the facility, and E1 was "trying to train" E5. E1 reported E5 did some cooking, but did not work as a caregiver or assistant caregiver. E1 further reported all facility personnel records were off site with E2. E1 reported E2 had taken records for E1, E2, E3, E4, and E5 to "make sure they were up to date," but had forgotten to return them to the facility. E1 reported E2 was "in class" and was unable to provide the records for the inspection. E1 acknowledged the manager failed to ensure personnel records for each employee were available for review.

Based on record review and interview, the manager failed to ensure a resident had a written service plan updated based on changes in the requirements in subsections (A)(3)(a)-(f) no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a written service plan for personal care services dated April 4, 2023. No subsequent service plan was available for review. R2's medical record also revealed a document titled "Health Care Power of Attorney" which indicated O1 was R2's medical power of attorney. 2. In an interview, the Compliance Officer asked R2 what R2's name was, where R2 was currently, and what R2 just had for lunch. R2 was unable to answer any of the Compliance Officer's questions and told the Compliance Officer R2 believed R2 was in New York. R2 was unable to discuss R2's care with the Compliance Officer. 3. In an interview, E1 reported R2 now required directed care services. E1 reported R2's condition had recently deteriorated and R2 was no longer able to direct R2's own care. E1 acknowledged R2's service plan had not been updated with 14 calendar days of a significant change in R2's cognitive condition.

Based on record review and interview, the manager failed to ensure a caregiver provided assistance with activities of daily living according to the resident's service plan, for two of two residents sampled. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(5) states "Activities of daily living" means "ambulating, bathing, toileting, grooming, eating, and getting in or out of a bed or a chair." 2. A review of R1's medical record revealed a written service plan for personal care services dated June 1, 2023. The service plan contained a section titled "Complete Bath" which stated R1 was to receive assistance with "Shower, every other day, by CG, Supervision needed." 3. Further review of R1's medical record revealed documents titled "Daily Activity Record (ADL)" dated July and August, 2023. The documents revealed R1 received assistance with showering on July 5, 12, 14, 19, 24, and 28, 2023, and on August 1, 4, 8, 11, 15, and 22, 2023. However, documentation to indicate R1 received assistance with showering at the frequency specified in R1's service plan in July and August, 2023 was not available for review. 4. A review of R2's medical record revealed a written service plan for personal care services dated April 4, 2023. The service plan contained a section titled "Complete Bath" which stated R2 was to receive assistance with "Shower, 2x weekly." 5. Further review of R1's medical record revealed a document titled "Daily Activity Record (ADL)" dated July, 2023. The document revealed R2 received assistance with showering on July 5, 12, 19, and 24, 2023. However, documentation to indicate R1 received assistance with showering at the frequency specified in R2's service plan in July 2023 was not available for review. 6. In an interview, E1 reported the frequency specified for showers in R1's service plan was incorrect, and R1 received showers twice a week from a certified nursing assistant. E1 reported E1 would update R1's service plan. E1 reported R2 refused to shower some days in July. E1 acknowledged assistance with bathing was not provided to R1 and R2 according to the frequency specified in R1's and R2's service plans.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a written service plan for personal care services dated June 1, 2023. The service plan stated the following services were to be provided for R1: -"Nail Care, Check finger nails daily and clean as needed"; -"Shave, Daily"; -"Comb Hair, Daily"; and -"Dressing, Assistance needed." 2. Further review of R1's medical record revealed activities of daily living (ADL) logs dated July and August, 2023. R1's ADLs included no documentation indicating the aforementioned services were provided to R1 in July or August, 2023. 3. In an interview, E1 reported caregivers provided all of the aforementioned services indicated in R1's service plan. R1 reported caregivers assisted R1 with dressing "at least twice a day." However, E1 acknowledged the services provided to R1 were not documented in R1's medical record. 4. A review of R2's medical record revealed a written service plan for personal care services dated April 4, 2023. The service plan stated the following services were to be provided for R2: -"Shampoo: 2X Weekly"; -"Dressing: Assist in Selecting Clothes, Assist in Putting on Shoes, Assist in Removing Clothes"; and -"Nail Care: Check Fingernails Daily & Clean as Needed." 5. Further review of R2's medical record revealed ADLs for July and August, 2023. R2's July and August ADLs included no documentation indicating the aforementioned services were provided to R2 in July or August, 2023. 6. In an interview, E1 reported R2's hair was shampooed each time R2 was showered. E1 also reported R2's fingernails were checked daily, and R2 received assistance with dressing "at least twice a day." However, E1 acknowledged the services provided to R2 were not documented in R2's medical record.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication administered to the resident, for one of two residents sampled. 1. A review of facility policies and procedures revealed a policy titled "Medication Order" which stated, "A medication order or also called "physician's order" or "doctor's order" shall be on file at the facility for every medication and treatment for which staff will be providing assistance...1. Doctor's orders should be obtained from a resident's physician before he or she moves into the facility." 2. A review of R1's medical record revealed a medication administration record (MAR) for July 2023. The MAR revealed R1 was administered the following medications as specified below on every day from July 1-31, 2023: -"Apixaban 5 MG (milligrams) Tab, Take one tablet by mouth twice a day for stroke prevention"; -"Bimatoprost 0.01% OPH Soln, Instill 1 drop in each eye at bedtime to control glaucoma"; -"Budesonide 4.5 MCG (micrograms), Inhale 2 inhalations by mouth twice a day"; -"Carbamide Peroxide 6.5% OTIC Soln, Instill 5 drops topically twice a day for ear wax removal"; -"Levothyroxine NA 88 MCG Tab, Take one tablet by mouth every morning for thyroid"; and -"Lisinopril 20 MG Tab, Take one tablet by mouth every morning for high blood pressure". 3. Further review of R1's medical record revealed a document titled "The Med Form," dated June 1, 2023. The document had a section stating, "Current VA Medications," beneath which the aforementioned medications were listed. However, the list was not signed by a medical practitioner and medication orders for the aforementioned medications were not available for review. 4. In an interview, E1 reported E1 thought the medication list in R1's medical record was electronically signed. E1 acknowledged R1's medical record did not contain medication orders from a medical practitioner for each medication administered to R1 in July, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccinations for influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d), for one of two residents sampled. Findings include: 1. A.R.S. \'a7 36-406(1) states: "The department shall...(d) Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized." 2. A review of R2's medical record revealed documentation indicating R2 was notified of the availability of vaccination for flu and pneumonia on April 8, 2022. However, no documentation to indicate R2 was notified of the availability of influenza and pneumonia vaccinations after April 8, 2022 was available for review. 3. In an interview, E1 reported E1 believed R2's representative was notified of the availability of the vaccinations for influenza and pneumonia in 2023. However, E1 acknowledged documentation of this notification was not available in R2's medical record.

Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements in Arizona Administrative Code (A.A.C.) R9-10-814(B)(2) at least once every six months throughout the duration of the resident's condition, for one of one resident sampled who was confined to a bed or chair because of an inability to ambulate even with assistance. Findings include: 1. A review of R2's medical record revealed a written service plan for personal care services dated April 4, 2023. R2's service plan included a section titled "Activities" which stated, "Transfer: With Assist of 2 Caregivers, Ambulates: No." 2. Further review of R2's medical record revealed a document titled "Consent for Resident's Stay in the Facility" which stated, "We, the undersigned Physician and Resident's Representative/POA, have reviewed Tulsi Assisted Living's scope of services. We have determined that the needs of [R2], who is confined to a bed/chair because of an inability to ambulate even with assistance can be met by the above named assisted living facility." The document was signed and dated by R2's physician on April 8, 2022. However, additional documentation to indicate the manager met the requirements in A.A.C. R9-10-814(B)(2) at least once every six months throughout the duration of R2's condition was unavailable for review. 3. In an interview, E1 acknowledged no examination signed and dated by R2's primary care provider at least once every six months throughout the duration of R2's condition was available for review.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, the means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed a sliding door leading from the dining area out to the back yard. The door had a mechanism to alert employees of the egress of a resident from the facility, however the mechanism did not sound when the Compliance Officer opened the door. The Compliance Officer observed the outside area in the backyard allowed residents to be at least 30 feet away from the facility. The Compliance Officer also observed an unlocked gate in the backyard which opened to the facility's driveway and front yard. 3. In an interview, E1 acknowledged the device to alert employees of the egress of a resident from the facility to the outside area through the back door was not in working order. E1 also acknowledged the gate in the facility's back yard did not control or alert employees of the egress of a resident from the facility. E1 acknowledged the back door and back yard gate were not controlled and did not alert employees of the egress of a resident from the facility.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. Findings include: 1. A review of facility documentation revealed a document titled "Yearly Disaster Plan Review" which showed the facility's disaster plan was reviewed on October 28, 2021. However, no documentation of subsequent disaster plan reviews was available for review. 2. In an interview, E1 reported E2 may have conducted a more recent disaster plan review, but E1 was not sure if and when the review was conducted. E1 acknowledged there was no evidence to indicate the facility's disaster plan was reviewed at least once every 12 months.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed documentation of disaster drills conducted on the following days and shifts: -July 17, 2022 "Day"; -July 18, 2022 "Night"; -January 22, 2022 "Night"; and -January 12, 2022 "Day". No additional disaster drill documentation was available for review. 2. In an interview, E1 reported the facility usually maintains two shifts, from 7:00 AM to 7:00 PM (Day) and from 7:00 PM to 7:00 AM (Night). E1 reported E1 thought E2 may have conducted more recent disaster drills, but was unable to confirm when or if the drills were conducted. E1 acknowledged disaster drills for employees were not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to safely evacuate residents in an emergency. Findings include: 1. A review of facility documentation revealed documentation of an evacuation drill conducted on October 18, 2021. However, documentation of subsequent evacuation drills was not available for review. 2. In an interview, E1 reported E1 was just hired as the facility's manager. E1 reported E1 thought E2 may have conducted more recent disaster drills, but was unable to confirm when or if the drills were conducted. E1 acknowledged evacuation drills for employees and residents were not conducted on each shift at least once every six months and documented.