Inspection Reports for
Royal Plaza of Olympus Living

.305.03 Change in Resident Health Status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, including inadequate skin checks and incomplete change of condition assessments (previously cited 9/12/2024).

.310.01.f Medication Distribution: the facility did not have as-needed (PRN) medications available for residents, including specific medications for Residents #1, #3, and #4; medications were reported to be on order.

.310.02.c Discontinued and Expired Prescriptions: the facility's medication destruction logs did not consistently include the date and method of disposal for destroyed medications; the medication technician stated use of a drug buster for destruction.

.310.02.d Discontinued and Expired Prescriptions: the facility medication destruction logs did not include two signatures when medications were destroyed; paper records lacked consistent signatures from 4/14/26 to 9/1/26, and the RCC was unaware of this rule.

39-3309.01 Negotiated Service Agreement: residents' NSAs did not clearly reflect needs or describe services, missing details on equipment use, wound care, ostomy care, and physical therapy; facility nurse stated NSAs lacked written instructions (previously cited 9/12/2024 and 5/7/2026).

.260.06 Toxic Chemicals: the facility was not maintained in a clean, safe, and orderly manner with strong urine odors in hallways and trash containing soiled incontinence products not removed daily as required.

.305.02.b Quarterly Nursing Assessments: residents did not receive their medications as ordered, with multiple missed doses due to medication availability and pharmacy delivery issues.

.320.01 Use of NSA: residents' Negotiated Service Agreements did not clearly reflect needs or services provided, with outdated information and lack of documentation on cognitive decline and assistance required (previously cited 9/12/2024).

.215.08.e. Corrective Action: the facility did not ensure effective corrective action was put into place to prevent incidents' recurrence for multiple residents, including falls on various dates (previously cited 10/2/2023).

.300.01. Licensed Registered Nurse (RN): the facility RN did not perform initial and/or quarterly assessments for 9 of 10 sampled residents, and the LPN confirmed these assessments were not completed (previously cited 5/26/2023).

.305.03. Resident Health Status: residents were not assessed by a facility nurse after experiencing changes in condition, including falls and surgery, as confirmed by the facility LPN.

.305.06. Self-Administered Medication: residents were not assessed every 90 days to ensure safety in self-administering medications, as stated by the facility LPN.

.310.04.e. Psychotropic or Behavior Modifying Medication: residents taking psychotropic medications longer than six months did not have six-month medication reviews completed (previously cited 5/26/2023).

.319. Comprehensive Assessment Requirements: the facility did not complete comprehensive assessments prior to admission for several residents, as stated by the administrator.

.320. Negotiated Service Agreement (NSA) Requirements: the facility did not develop interim care plans for several residents upon admission, as stated by the administrator.

.320.01. Use of NSA: residents' NSAs did not consistently or clearly reflect needs or describe specific services, with housekeeping, money management, and night needs omitted for all sampled residents due to electronic records system limitations.

.330.14. As Worked Schedules: the facility's as-worked schedules did not document exact times the administrator or administrator in training were present, nor the dates and times the facility RN was present, as confirmed by the administrator.

.450. Requirements for Food and Nutritional Care Services: the facility did not have a Certified Food Protection Manager at the time of survey; the dietary manager was in the process of certification and no current staff were certified.

.161.04 Designated Smoking Areas: facilities designated smoking area is not clearly marked with signage and location is not clearly designated within facility written policy.

.250.10.b Heating, Ventilation, and Air-Conditioning (HVAC): facility failed to provide a safety barrier for the fireplace located in the front entryway sitting area.

.250.10.d Heating, Ventilation, and Air-Conditioning (HVAC): the facility failed to present documentation of the last known damper testing for dynamic dampers located in the main entry/clear-story stairwell; dampers are required to be tested not less than each four years.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: repeat punch from 3/2/2023 survey; facility population is currently comprised of hearing and vision impaired residents; currently no resident sleeping rooms are provided with audible/visual notification devices; occupant notification shall be provided in accordance with NFPA 101, Chapter 9, Section 9.6.3.

.405.02.a Prohibited Applications: medical equipment is prohibited from being plugged into a relocatable power tap (RPT); room #106 has an oxygen concentrator plugged into a relocatable power tap.

.405.02.b Prohibited Applications: daisy-chains are prohibited with the use of a relocatable power tap; room #144 has a device plugged into a relocatable power tap, plugged into a surge protector and then into the wall outlet.

.405.02.c Prohibited Applications: appliances are prohibited from being plugged into a relocatable power tap; room #145 has a refrigerator, coffeemaker, microwave and water dispenser plugged into a relocatable power tap; room #121 has a coffeemaker plugged into a relocatable power tap.

.215.01 Administrator Responsibility: the facility did not ensure policies and procedures were implemented, including delayed police notification after a resident was missing and found deceased, and failure to follow behavior management policies for residents exhibiting disruptive behaviors.

.215.08.e Corrective Action: residents with dementia sustained multiple falls despite repeated interventions, which were ineffective or inappropriate, and the administrator was unsure of appropriate interventions.

.215.08.f Notification to Licensing Agency within One Business Day: the facility failed to notify Licensing and Certification within one business day of a resident's death and hospitalizations due to falls.

.320.08 Periodic Review: negotiated service agreements were not updated to reflect significant changes in residents' health status and care needs, including lack of instructions for confused residents and those with elopement history.

.330.04 Resident Care Records: care records were not kept current, complete, or authentic; caregiver notes lacked dates, times, and signatures, and resident behaviors and elopements were not documented.

.330.06.a Behavior Documentation: the facility did not evaluate behaviors of residents exhibiting yelling, hitting, exit seeking, and refusals of care, and one resident was started on antipsychotic medication without evaluation.

.330.06.b Behavior Documentation: the facility did not develop behavior plans with interventions after residents engaged in maladaptive behaviors.

.600.04.a Sufficient Personnel: the facility did not have sufficient staff on every shift to meet residents' needs, resulting in inadequate supervision, especially for residents with dementia and during evening and weekend shifts.

.645.02 Delegation: seven of eight staff passed medications without delegation by the facility nurse, including one staff member who had never been delegated.

.300.01 Licensed Registered Nurse (RN): the facility's RN did not perform quarterly assessments for 6 of 10 sampled residents, with one assessment seven months overdue; the RN stated they were behind on completing the assessments.

.305.02.b Current Medication Orders and Treatment Orders: the facility RN did not ensure residents received medications as ordered, including residents who missed lisinopril, Movantik, hydroxychloroquine, prednisone, diphenhydramine, and alendronate.

.310.01.g Medication Distribution System: Resident #2 and two unsampled residents did not have ordered PRN medications available; staff were unaware that PRN medications were missing.

.310.04.e Psychotropic or Behavior Modifying Medication: psychotropic medication reviews were not consistently completed for residents taking medications longer than six months; the RN stated she was behind on completing them.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: no documented testing of the 2-hour rated doors between Assisted Living and Skilled Nursing sides; hearing-impaired residents not accounted for in acuity charting; no audible or visible notification devices provided (occupant notification required by NFPA 101, Chapter 9, Section 9.6.3).

.405.01.a Electrical installations and equipment: extension cords and multiple plug adapters are prohibited; room 244 was using a multiple plug adapter, corrected on site 3/2/23.

.405.02.c Prohibited applications: relocatable power taps are prohibited with the use of appliances; activities room was using a relocatable power tap to supply power to an oscillating fan unit.

.410 Requirements for emergency actions and fire drills: emergency egress and relocation drills were not documented as conducted at least six times per year; drills did not document evacuation or use of designated assembly points as outlined in the emergency action plan.

.215.02 Availability of Administrator: the facility did not consistently have a licensed administrator to oversee the daily operations, with the administrator present only 20 days in May, 9 days in June, 13 days in July, and 3 days in August 2022; the operations manager confirmed the administrator lives in Arizona.