Five Roses Adult Care Home III

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for nine of nine residents sampled. Findings include: 1 . A review of R1's medical record revealed a medication list dated April 15, 2025. The medications list included the following: -Acetaminophen 325 MG 2 tablets three times a day; -Aspirin 81 MG tablet once a day; -Buspirone 15 MG tablet three times a day; -Cetirizine Hydrochloride 10 MG tablet once a day; -Divalproex Depakote Sprinkles 125 MG 3 capsules two times a day; -Donepezil 10 MG tablet once a day; -Famotidine 20 MG tablet once a day; -Levothyroxine 25 MCG tablet once a day; -Memantine 10 MG tablet once a day; -Mirtazapine 30 MG tablet once a day; -Trazodone 100 MG 2 tablets once a day; -Venlafaxine 75 MG tablet once a day; and -Venlafaxine 37.5 MG tablet once a day. However, a review of R1's Medication Administration Record (MAR) sheet for April 2025 revealed the above medications were not documented as administered from April 26, 2025, to April 28, 2025. 2 . A review of R2's medical record revealed a medication list dated March 7, 2025. The medications list included the following: -Clopidogrel Bisulfate 75 MG tablet once a day; -Clonidine HCL 0.1MG tablet two times a day; -Docusate 50 MG/Sennoside 8.6 MG tablet twice a day; -Donepezil HCL 10 MG tablet once a day; -Folic Acid 1 MG tablet once a day; -Metformin HCL 500 MG tablet once a day; -Metoprolol ER Succinate 50 MG tablet once a day; -Nifedipine ER 90 MG tablet once a day; -Rosuvastatin Calcium 10 MG tablet once a day; -Sertraline HCL 100 MG tablet once a day; -Spironolactone 25 MG tablet once a day; and -Trazodone 50 MG tablet once a day. However, a review of R2's MARs for April 2025 revealed the above medications were not documented as administered from April 26, 2025, to April 28, 2025. 3 . A review of R3's medical record revealed a medication list dated December 1, 2024. The medications list included the following: -Atorvastatin 20 MG tablet once a day; -Glipizide ER 2.5 MG tablet once a day; -Lamotrigine 25 MG 2 tablets twice a day; -Lisinopril 10 MG tablet once a day; -Memantine 5 MG tablet once a day; -Metformin 500 MG tablet twice a day; -Quetiapine Fumarate 50 MG tablet once a day; -Quetiapine Fumarate 150 MG tablet once a day -Trazodone 50 MG tablet 1/2 tablet twice a day; -Trazodone 100 MG 2 tablets once a day; and -Depakote 125 MG capsule once a day. However, a review of R3's MARs for April 2025 revealed the above medications were not documented as administered from April 26, 2025, to April 28, 2025. 4 . A review of R4's medical record revealed a medication list dated April 8, 2025. The medications list included the following: -Acetaminophen 500 MG 2 tablets three times a day; -Amlodipine Besylate 10 MG tablet once a day; -Celexa 20 MG tablet once a day; -Docusate Colace 100 MG tablet two times a day; -Depakote Divalproex 125 MG 3 capsules once a day; -Depakote Diva

Based on documentation review and interview, the manager failed to ensure a pest control program that complies with A.A.C. R3-8-20l(C)(4) was implemented and documented. Findings include: 1 . A review of facility documentation revealed no documentation of a pest control program available for review at the time of inspection. 2 . In an interview, E1 reported E1's relative had been spraying for bugs, but is not certified to spray. E1 acknowledged a pest control program was not available for review at the time of inspection.

Based on record review and interview, the manager failed to ensure a resident's service plan was completed no later than 14 calendar days after the resident's date of acceptance. Findings include: 1 . A review of R9's medical record revealed documentation of a completed service plan was not available for review at the time of inspection. Based on R9's admittance date, this documentation was required. 2 . In an interview, E1 acknowledged R9's medical record had no documentation of a service plan.

Based on record review and interview, the manager failed to ensure that services provided were documented in the resident's medical records for seven of nine residents sampled. Findings include: 1 . A review of R1's medical record revealed a service plan which included the following services: -Skin checks every bath and shower, and as needed; -Fluids encouraged daily; and -Incontinence checks daily. However, a review of R1's Activities of Daily Living (ADL) sheet for April 2025 revealed the services were not documented as provided from April 26, 2025, to April 28, 2025. 2 . A review of R3's medical record revealed a service plan which included the following services: -Skin checks every bath and shower, and as needed; -Fluids encouraged daily; and -Incontinence checks daily. However, a review of R3's ADLs for April 2025 revealed the services were not documented as provided from April 26, 2025, to April 28, 2025. 3 . A review of R4's medical record revealed a service plan which included the following services: -Skin checks every bath and shower, and as needed; -Fluids encouraged daily; and -Incontinence checks daily. However, a review of R4's ADLs for April 2025 revealed the services were not documented as provided from April 26, 2025, to April 28, 2025. 4 . A review of R5's medical record revealed a service plan which included the following services: -Skin checks every bath and shower, and as needed; -Fluids encouraged daily; and -Incontinence checks daily. However, a review of R5's ADLs for April 2025 revealed the services were not documented as provided from April 26, 2025, to April 28, 2025. 5 . A review of R6's medical record revealed a service plan which included the following services: -Skin checks every bath and shower, and as needed; -Fluids encouraged daily; and -Incontinence checks daily. However, a review of R6's ADLs for April 2025 revealed the services were not documented as provided from April 26, 2025, to April 28, 2025. 6 . A review of R7's medical record revealed a service plan which included the following services: -Skin checks every bath and shower, and as needed; -Fluids encouraged daily; and -Incontinence checks daily. However, a review of R7's ADLs for April 2025 revealed the services were not documented as provided from April 26, 2025, to April 28, 2025. 7 . A review of R8's medical record revealed a service plan which included the following services: -Skin checks every bath and shower, and as needed; -Fluids encouraged daily; and -Incontinence checks daily. However, a review of R8's ADLs for April 2025 revealed the services were not documented as provided from April 26, 2025, to April 28, 2025. 8 . In an interview, E1 acknowledged services were not documented as provided from April 26, 2025, to April 28, 2025, for R1, R3, R4, R5, R6, R7, and R8.

Based on record review and interview, the manager failed to ensure if a verbal order for a resident's medication is received from a medical practitioner by the assisted living facility the verbal order is documented in the resident's medical record, for two of three residents sampled. Findings Include: 1. A review of R1's medical record revealed a medication administration record (MAR) for August 2023. The MAR documented Trazadone 50 mg was administered once a day at bedtime on August 1-2, 2023. 2. A review of R1's medical record revealed a medication order for Trazadone 50 mg tablet, one tab every night at bedtime as needed for Insomnia. 3. In an interview, E1 reported Trazadone had recently been changed from being taken as needed to being taken every day. E1 acknowledged a verbal order was not documented in the resident's medical record. 4. A review of R2's medical record revealed a MAR for August 2023. The MAR documented Levothyroxine 100 mcg was administered once a day in the mornings on August 1-3, 2023. 5. A review of R2's medical record revealed a medication order for Levothyroxine 75 mcg, one tablet once daily at 7:00 AM before breakfast. 6. In an interview, E1 reported Levothyroxine had recently been changed from 75 mcg to 100 mcg. E1 acknowledged a verbal order was not documented in the resident's medical record.

Based on 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), if required for the individual according to subsection (A)(8), for one of three caregivers sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of E3's personnel record revealed documentation of evidence of freedom from infectious TB was not available for review. 2. In an interview, E1 reported E3 had current documentation of evidence of freedom from infectious TB. However, the documentation was not provided for review during the inspection or during the exit interview.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the refusal to be immunized for influenza (flu) and pneumonia, for one of three residents sampled. Findings include: A.R.S. \'a7 36-406(1)(d) The department shall: 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. 1. A review of R2's medical record revealed documentation of notification of the availability of vaccination for flu and pneumonia vaccination dated in 2020. However, documentation of the notification for the flu and pneumonia vaccinations available to R2 on site on a yearly basis was not available for review. 2. In an interview, E1 reported R2 declined vaccinations. E1 acknowledged documentation of R2's refusal to be immunized for flu and pneumonia on a yearly basis was not available for review. Technical assistance was provided on this Rule during the onsite compliance inspection completed on July 21, 2022.