Rosa De Saron Care Home

Based on documentation review and interview, the assisted living home failed to maintain a standardized form for each resident which included all of the information prescribed in subsection A of this section. Findings include: 1. A review of facility documentation revealed no evidence of a standardized emergency responder form for each resident as required. 2. In an interview, E1 acknowledged the facility had not developed and maintained a form which included all of the information prescribed in subsection A of this section, for each resident. E1 further reported E1 usually provided a copy of the medication list and allowed the first responders to review the service plan, but not take the document.

Based on record review and interview, the manager failed to ensure a resident submitted documentation dated within 90 days prior to admission, signed by a registered nurse or medical practitioner, stating whether the resident would require continuous medical services, continuous or intermittent nursing services, or restraints, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed no documentation, dated within 90 days prior to admission, signed by a registered nurse or medical practitioner, stating whether the resident would require continuous medical services, continuous or intermittent nursing services, or restraints. 2. In an exit interview, the findings were reviewed with E1. E1 acknowledged the record did not include the documentation dated within 90 days prior to admission, signed by a registered nurse or medical practitioner, stating whether the resident would require continuous medical services, continuous or intermittent nursing services, or restraints. E1 believed the document was signed and emailed to the facility; however, E1 was unable to locate the email.

Based on observation, record review, and interview, the manager failed to ensure the facility did not accept or retain an individual if the individual required restraints, including the use of bedrails, for one of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a document titled, “DETERMINATION FOR ADMISSION”, dated July 11, 2025, which stated, "…8. Does this person require restraints; chemical or physical? (i.e. seat belt, lap buddy, bedrails) ____ Yes ____ No". The medical provider underlined “physical”, circled “bedrails”, and placed a checkmark beside yes, indicating R2 needed restraints. 2. In an interview, E1 confirmed the bedrails were to keep R2 from getting out of bed due to a risk of falls. 3. During a tour of the facility, this Compliance officer observed R2’s bed to be equipped with bedrails that were the length of the bedside. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed no evidence of a residency agreement. Based on the date of R2’s acceptance, a completed residency agreement was required. 2. In an exit interview, the findings were reviewed with E1. E1 acknowledged R2’s medical record did not include a residency agreement. This is a repeat citation from the on-site compliance and complaint inspection conducted on August 18, 2023.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance for one of two resident records reviewed. The deficient practice posed a risk as there was no completed service plan to direct services to be provided to a resident. Findings include: 1. A review of R2’s medical record revealed no evidence of an initial service plan. Based on R2’s date of acceptance, an initial service plan was required. 2. In an interview, E1 acknowledged R2's medical record did not include a service plan which was completed within 14 calendar days of R2's date of acceptance. E1 further acknowledged R2 received directed care level services and did not have an initial service plan.

Based on record review and interview, the manager failed to ensure a resident had a written service plan which, when initially developed and when updated, was signed and dated by the resident or resident's representative, the manager, and if a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan for one of two resident records reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed an initial service plan for directed care level of services, dated July 9, 2025, which included medication administration. 2. Further review, revealed the service plan did not include the required signatures of the resident or the resident's representative, the manager, or the nurse or medical practitioner who reviewed the service plan. 3. In an exit interview, the findings were reviewed with E1. E1 reported R1’s service plan was completed and signed, though E1 was unable to locate a signed service plan for R1.

Based on record review and interview, the manager failed to ensure that a caregiver or an assistant caregiver documented the services provided in the resident’s medical record for two of two requested resident records. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of resident records revealed no documentation of services provided to R1 and R2. 2. In an interview, E1 reported E1 had not created the logs to track services provided for the month of November. This Compliance Officer requested documentation of services provided prior to November; however, none were provided for review. 3. In an interview, E1 acknowledged the facility failed to ensure a caregiver or assistant caregiver documented the services provided in the resident’s medical record.

Based on record review and interview, the manager failed to ensure that a resident’s medical record contained documentation of medication administered to the resident that included the date and time of administration; the name, strength, dosage, and route of administration; and the name and signature of the individual administering the medication. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed an unsigned service plan, dated July 9, 2025, for directed care services including medication administration. 2. A review of R1's medication revealed a bottle of “Kirkland Allergy ALLER-TEC Cetirizine Hydrochloride Tablets, 10mg”. A review of R1’s medication orders revealed no order for the allergy medication. 3. In an interview, E1 reported it was an over-the-counter medication, and R1 took it daily. E1 was unable to provide an order for the medication. A review of R1's Medication Administration Record (MAR) revealed no documentation of the dates and times when the ALLER-TEC was administered. Further review revealed the MAR did not include the name, strength, dosage, route of administration, or the name and signature of the person who administered the medication. 4. The review of R1's medical record revealed a signed medication order dated November 13, 2025. The medication order stated, “1) D/C trazodone 50 mg, 2) Trazodone 100 mg. Take 1 tablet by mouth daily @ HS”. The document revealed the order was texted to E1 and sent to R1’s pharmacy on November 13, 2025 at 1:49 PM. 5. A review of R1’s MAR dated November 2025 revealed documentation R1 continued being administered Trazodone 50 mg from November 1, 2025, until November 20, 2025. 6. In an interview, E1 reported the medical provider advised the facility to administer two Trazodone 50 mg, until finished, and then begin using the Trazodone 100 mg. E1 reported R1 had been administered 100 mg Trazodone since the order was received; however, E1 did not update the MAR to reflect the change in the strength of the Trazadone. 7. A review of R2’s medical record revealed R2 did not have a MAR or documentation of the administration of R2’s medication which included the date and time of administration; the name, strength, dosage, and route of administration; and the name and signature of the individual administering the medication. 8 In an interview, E1 confirmed R2 was administered medications from R2’s admission date through the date of the inspection, November 21, 2025. E1 reported medications were administered from the prepackaged medication cards and acknowledged R2 did not have a MAR set up yet to document the medication administration. A review of the signed orders revealed Metoprolol 25 mg was to be administered "BID @ 0800, 2000 (Hold for SBP < 110)". E1 acknowledged there was no documentation of R2's blood pressure readings before the administration, as ordered. 8. In an exit in

Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order for two of two resident records reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed an unsigned service plan, dated July 9, 2025, for directed care services including medication administration. 2. A review of R1's medication revealed a bottle of “Kirkland Allergy ALLER-TEC Cetirizine Hydrochloride Tablets, 10mg”. A review of R1’s medication orders revealed no order for the allergy medication. 3. In an interview, E1 reported it was an over-the-counter medication, and R1 took it daily. E1 was unable to provide an order for the medication. 4. A review of R2’s medical record revealed a signed list of medication orders dated November 4, 2025. The list included daily and as-needed medications. In an interview, E1 confirmed R2 received directed care services and medication administration. R2’s medical record did not include a MAR (medication administration record) or documentation of the administration of R2’s daily or as-needed medication. In an interview, E1 reported medications were administered from the prepackaged medication cards and acknowledged R2 did not have a MAR set up yet, though received medication administration from R2’s admission date through the date of the inspection, November 21, 2025. 5. A review of R2’s medication revealed two plastic tubs of medication cards for R2. The Compliance Officer observed several white pills in the bottom of the tub. Further review revealed the pills to be Lithium Carbonate 300 mg. It is not clear R2 was administered the Lithium as ordered. 6. A review R2's signed medication orders revealed an order for “Metoprolol 25 mg, BID @ 0800, 2000 (Hold for SBP < 110)”. E1 acknowledged there was no documentation of R2's blood pressure before the administration, as ordered. E1 further reported that E1 believed the blood pressure checks were reduced to once per day; however, acknowledged there was no documentation of the blood pressure measurements. 7. In an exit interview, the findings were reviewed with E1 and no additional information was provided. This is a repeat citation from the on-site compliance and complaint inspection conducted on August 18, 2023.

Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked self-contained unit used only for medication storage. The deficient practice posed a health and safety risk, if medications were accessible to residents. Findings include: 1. During a facility inspection, the Compliance Officer observed a refrigerator in the kitchen. The refrigerator contained bottle of “Equate Regular Strength Stomach Relief Bismuth Subsalicylate 525 mg”, unsecured in the refrigerator door. 2. During the inspection, the Compliance officer observed three medications sitting on the printer unsecured: a bottle of MiraLAX, a bottle of Milk of Magnesia, and a box of lidocaine patches. During the inspection, the manager left the area where the printer and unsecured medications were located to attend to residents and accompany the Compliance Officer on a tour. 3. In an interview E1 acknowledged the medication was not stored secured and in a separate locked self-contained unit, used only for medication storage. E2 immediately removed the medication and reported the refrigerated medication was E1’s medication and did not belong to a resident.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and were inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed a metal shelf which contained food. The shelf was located in a small hallway between the kitchen and a bedroom. Besides food, the shelf contained a clear spray bottle of liquid with faded letters. 2. In an interview, E1 opened the bottle and smelled of the liquid and said the liquid was “Awesome” cleaner. 3. In an exit interview, the findings were reviewed with E1, and E1 acknowledged the poisonous or toxic material was not kept in a clearly labeled container separate from food in a secure area, inaccessible to residents.

Based on documentation review and interview, the governing authority failed to notify the Department according to Arizona Revised Statutes (A.R.S.) \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. Findings include: 1. During the on-site inspection, the Compliance Officer observed a posted manager certificate identifying E1 as the manager. 2. In an interview, E1 reported E1 became the new manager in October of 2022. 3. A review of Department documentation revealed no evidence to indicate the governing authority notified the Department when there was a change in the manager. 4. In an interview, E1 acknowledged the facility did not notify the Department of a change in the facility's manager.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the requirements in R9-10-807(D)(1-10) for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a residency agreement between R1 and a facility other than Rosa De Saron Care Home, signed on November 4, 2021, prior to R1's admission date. 2. In an interview, E1 acknowledged R1's residency agreement was from another facility, which was owned by the same owner. E1 was unaware of the need for a new residency agreement. 3. A review of R2's medical record revealed no evidence of a residency agreement. E1 reported the agreement was created and signed by the facility. E1 reported the agreement was provided to R1's representative and it was not returned to the facility. 4. In an interview, E1 acknowledged the residency agreement for R1 did not include the current facility where the resident resides and no residency agreement was included in R2's medical record.

Based on record review and interview, the manager failed to ensure a resident had a written service plan which when initially developed and when updated, was signed and dated by: the resident or resident's representative; the manager, for one of two records sampled. Findings include: 1. A review of R2's medical record revealed an initial service plan, for personal care services and medication administration, dated November 22, 2022. The service plan did not include the required signature of the resident or resident's representative. 2. A review of R2's medical record revealed a service plan update, which noted no changes, dated May 3, 2023. The service plan update did not include the required signatures of the resident or resident's representative and the facility's manager. 3. In an interview, E1 acknowledged the service plans were not signed as required by the resident, resident's representative, or the manager. E1 reported issues with R2's representative and was unaware R2 could sign the document.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two resident records sampled. Findings include: 1. A review of R1's medical record revealed a signed list of medications dated March 14, 2023. The medication list included: - "CARVEDILOL 3.125MG TABLETS, 1TAB PO TWICE DAILY W FOOD HOLD FOR BP <100 OR HR <60"; - "LISINOPRIL 5MG TABLETS, 1 TAB PO DAILY HOLD FOR BP <100 OR HR <60"; - "HYDROXYZINE 25MG TABLETS, 1-2 TABS PO AS NEEDED FOR ANXIETY"; and - "IBUPROFEN 800 MG TABLET, 1 TAB PO EVERY 8 HOURS AS NEEDED FOR PAIN". 2. A review of R1's medical record revealed a "RESIDENT VITAL SHEET", which did not include tracking of R1's heart rate as required by the order. 3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated August 2023. The MAR revealed Carvedilol 3.125MG and Lisinopril 5MG were administered to R1 at 8 a.m. on August 7, 2023, though the "RESIDENT VITAL SHEET" recorded the blood pressure measurement of 97/58 at 8 a.m. 4. A review of R1's medication organizer revealed one Ibuprofen 800MG and one Hydroxyzine 25MG in the daily 8 p.m. medication compartment. In an interview E1 reported the medications were given daily as ordered medications, though they were scheduled to be administered as needed for pain and anxiety. 5. A review of R2's medical record revealed an order, dated June 23, 2023, for "CARBOXYMETHYLCELLULOSE 1% OPH GEL 0.2ML, INSTILL 1 DROP TO BOTH EYES TWICE A DAY FOR DRY EYE". 6. A review of R2's MAR dated August 2023, revealed no documentation of the administration of "CARBOXYMETHYLCELLULOSE". A review of R2's medication revealed two boxes of "CARBOXYMETHYLCELLULOSE" in sealed unopened boxes. 7. In an interview, E1 acknowledged medications had not been administered to R1 and R2 in compliance with medication orders.