Royal Assisted Living, INC

Based on record review and interview, the health care institution's chief administrative officer failed to ensure the health care institution established, documented, and implemented tuberculosis infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution, for two of two personnel sampled. Findings include: 1. A review of E1 and E2's personnel records did not include documentation of completed annual training on recognizing the signs and symptoms of TB. Given E1's and E2's date of hire, this documentation was required. 2. In an interview, E1 acknowledged the personnel records did not include documentation of annual training on recognizing the signs and symptoms of TB and reported they were not aware of the requirement. 3. In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on record review and interview, the manager failed to ensure, for one of two sampled caregivers, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E2's personnel record revealed a card from "NationalCPRFoundation" dated February 1, 2026. E2’s card indicated the program was completed online, and there was no documentation to reflect E2's training included a demonstration of E2's ability to perform CPR. 2. A review of the R1’s medication administration record (MAR) dated February 1, 2026 through February 17, 2026, reflected E2 provided medication administration to R1 on February 1, 2026; February 7, 2026; February 8, 2026; February 14, 2026; and February 15, 2026. 3. In an interview, E1 stated they were not aware online CPR training was not sufficient and indicated in-person training would be completed immediately. 4. In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. 36-411(C), for two of two personnel sampled. Findings Include: 1. A review of E1 and E2’s personnel files included copies of E1's and E2's Fingerprint Clearance Cards (FPC); however, E1's and E2's personnel records did not include documentation of good faith efforts to verify the current status of the employees’ fingerprint clearance cards. 2. In an interview, the findings were discussed with E1. E1 indicated E1 was not aware of the requirement to verify the FPC and thought only the APS registry needed to be verified. 3. In an exit interview, the findings were reviewed with E1 and no further information was provided. TA was provided for this deficiency during the compliance inspection conducted on September 20, 2024.

Based on documentation review, record review, and interview, the manager failed to ensure, for two of two sampled caregivers, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of the facility work schedule revealed E2 had worked on the 6 AM to 2 PM shift on September 1,2,9,10, and 19, and had worked on the 2 PM to 10 PM shift on September 3,6,8,14,15, and September 17, 2024. 2. A review of E2's personnel records revealed a Basic Life Support (BLS) "CPR and AED" training certifications dated February 19, 2024 with a marked expiration of February 2026. However, documentation of First Aid training for E2 was not available for review. 3. A review of the facility work schedule revealed E3 had worked on the 10 PM to 6 AM shift on September 2,3,4,5,6,9,10,11,12,13,16,17,18, and September 19, 2024. 4. A review of E3's personnel records revealed a CPR and First Aid training certification dated April 27, 2022 with a marked expiration of April 27, 2024. However, current documentation of CPR and First Aid training for E3 was not available for review. 5. In an interview, E1 acknowledged E2's and E3's personnel records did not include documentation of current CPR and First Aid training certification.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of two residents sampled. Findings include: 1. R9-10-113.A.2.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. R9-10-113.A.2.b states, "If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and, ii. annually obtaining documentation of the individual ' s freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101;" 3. A review of R1's medical record revealed documentation of a positive skin test and a doctor's determination that .R1 did not have active TB. However, documentation of a baseline screening conducted at the time of R1's admission and documentation of annual symptom screenings were not available for review. Based on R1's date of admission, both the baseline TB screening and Annual symptom screenings were required. 4. A review of R2's medical record revealed completed documentation of R2's freedom from infectious TB was not available for review. R2's medical record included a negative Mantoux skin test, however, documentation of a baseline screening assessment of R2 risks of prior exposure to infectious tuberculosis and a determination if R2 had signs or symptoms of tuberculosis, were not available for review. 5. In an interview, E1 acknowledged completed documentation of R1's and R2's freedom from infectious TB had not been provided for review.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated 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 service plan, dated May 1, 2024 for directed care services. The service plan stated R2 was receiving hospice services. 2. A review of R2's medical record revealed a service plan update, dated August 19, 2024 , which stated there were no changes to the current service plan. 3. A review of R2's medical record revealed an Medication Administration Record (MAR) dated September 2024. The MAR documented the following: - On September 5, 2024 through September 8, 2024, at, "8-9 AM", the MAR had been left blank for all medications, indicating no medications had been administered. However, documentation of the reason medication had not been administered was not available for review; - For, "Quetiapine 25 mg oral tablet, Take 1 tablet by oral route every morning, in addition to the blank section on September 5-8, on September 9 a caregiver's initials had been crossed out, and the MAR had been left blank on September 10 and September 12, 2024, again without explanation regarding why the medication had not been administered; and - On September 1, 2024 and September 4, 2024, at "5-6 PM," and at, "8-9 PM," the Mar had been left blank for all medications, indicating no medications had been administered. However, documentation of the reason medication had not been administered was not available for review. 4. In an interview, E1 reported the reason for the gap in the Quetiapine administration for R2 was because hospice had dropped R2, and R2 had to make an appointment with a new doctor, and that doctor refused to order refills for R2 until their first in-person appointment, which has resulted in a gap in the availability of R2's medications. 5. A review of R2's medical record revealed a discharge order from hospice was not available for review. R2's medical record included no other information regarding R2's current hospice status. 6. In an interview, E1 acknowledged R2's service plan had not been updated within 14 calendar days after R2 stopped receiving hospice services.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two sampled residents who received medication administration. Findings include: 1. A review of R2's medical record revealed a service plan, updated August 19 2024, for directed care services including medication administration. 2. A review of R2's medical record revealed an Medication Administration Record (MAR) dated September 2024. The MAR documented the following: - On September 5, 2024 through September 8, 2024, at, "8-9 AM", the MAR had been left blank for all medications, indicating no medications had been administered. However, documentation of the reason medication had not been administered was not available for review; - For, "Quetiapine 25 mg oral tablet, Take 1 tablet by oral route every morning, in addition to the blank section on September 5-8, on September 9 a caregiver's initials had been crossed out, and the MAR had been left blank on September 10 and September 12, 2024, again without explanation regarding why the medication had not been administered; and - On September 1, 2024 and September 4, 2024, at "5-6 PM," and at, "8-9 PM," the Mar had been left blank for all medications, indicating no medications had been administered. However, documentation of the reason medication had not been administered was not available for review. 3. In an interview, E1 acknowledged the MAR provided for R2 did not accurately document the medications administered to R2.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, updated March 22, 2023, for personal care services including medication administration. 2. A review of R1's medical record revealed a signed list of medication orders dated August 9, 2021. The list included: - "Start Amlodipine 2.5 mg 1x a day." 3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated July 2023. However, the MAR did not include Amlodipine. 4. A review of R1's medical record revealed an order to discontinue administration of Amlodipine was not available for review. 5. In an interview, E1 acknowledged R1's orders and MAR did not match and indicated medications had not been administered to R1 in compliance with an order. E1 reported R1's Amlodipine had been discontinued and updated orders would need to be obtained.

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. Findings include: 1. A review of the facility work schedule revealed the facility worked on three shifts per day. 2. A review of facility disaster drills conducted during the previous twelve months revealed drills were conducted on December 2022 and March 2023 on all three shifts. However, documentation of disaster drills conducted on all three shifts in June of 2023 were not available for review. 3. In an interview, E1 acknowledged documentation of disaster drills for June of 2023 had not been provided to the Compliance Officer upon request. E1 reported the drills had been conducted, but E1 reported being unable to locate the documentation of the drills during the on-site inspection.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet below the kitchen counter which did not have a lock. Inside the cabinet, the Compliance Officer observed a bottle of, "LA's Totally Awesome Orange All purpose degreaser." The bottle included a warning label which stated, "Warning; eye irritant. Contains 2-butoxy ethanol....if swallowed, give 1 or 2 glasses of water and call a physician, poison control center, or emergency room immediately." 2. During an environmental inspection of the facility, the Compliance Officer observed the laundry room door had been left open and unattended. Inside the laundry room, the Compliance Officer observed a closet door had a lock, however, the closet had been left unlocked at the time of the inspection. Inside the close, the Compliance Officer observed bottles of, "Awesome Orange," glass cleaner, "Pinol," isopropyl alcohol, "WD-40", "Lysol Disinfectant," and, "Pledge." 3. In an interview, E1 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on August 4, 2022.