FIVE ROSES ADULT CARE HOME III

INSP-0129989

Complete

Date: 4/29/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-05-12

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on April 29, 2025:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

R9-10-808.A.1. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 1. Is completed no later than 14 calendar days after the resident's date of acceptance;

Evidence/Findings:

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.

Temporary Solution:

Complete Service Care Plan for newly moved in resident

Permanent Solution:

Manager and manager designee have checklist in the contact and all addendums and will be the checklist on top of every new move in. Our home's form will be used for new admits to the facility, any significant changes and when residents are admitted to the hospital. We have developed a calendar that indicates the annual due dates for all residents.

Person Responsible:

Rebeica Ratiu, Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-808.C.1.g. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and

Evidence/Findings:

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.

Temporary Solution:

Get together with the employees from shifts for 4/26/2025 - 4/28/2025 and review residents 1 -through 8. Sign for ADLs for the missing dates to be up-to-date.

Permanent Solution:

All staff was educated on the requirements of documenting activities of daily living; specifically the caregiver staff on the importance of completing it on time multiple times a day and as needed. Each employee to set an alarm or multiple ones to ensure they carve out time to sit down and document activities of daily living for each resident.

Person Responsible:

Rebeica Ratiu, manager

Deficiency #3

Rule/Regulation Violated:

R9-10-816.B.3.c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: c. Is documented in the resident's medical record.

Evidence/Findings:

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 Divalproex 125 MG 4 capsules once a day;-D-Mannose 1200 MG capsule once a day;-Furosemide Lasix 20 MG tablet once a day;-Hydroxychloroquine 200 MG tablet twice a day;-Levothyroxine 0.125 tablet once a day;-Losartan 100 MG tablet once a day;-Pregabalin 50 MG capsule three times a day;-Seroquel 25 MG tablet once a day;-Sodium Chloride 1,000 MG tablet three times a day; and-Trazodone 200 MCG tablet once a day.However, a review of R4's MARs for April 2025 revealed the above medications were not documented as administered from April 26, 2025, to April 28, 2025. 5 . A review of R5's medical record revealed a medication list dated April 15, 2025. The medications list included the following:-Aspirin 81 MG tablet once a day;-Acetaminophen 325 MG tablet twice a day;-Metoprolol Succinate ER 25 MG tablet once a day;-Nitrofurantoin Macrodantin MCR 50 MG capsule once a day;-Quetiapine Fumarate 25 MG tablet twice a day;-Quetiapine Fumarate 50 MG tablet twice a day;-Thiamine HCL 100 MG tablet once a day; and-Trazodone 50 MG tablet once a day.However, a review of R5's MARs for April 2025 revealed the above medications were not documented as administered from April 26, 2025, to April 28, 2025. 6 . A review of R6's medical record revealed a medication list dated April 15, 2025. The medications list included the following:-Buspirone 10 MG tablet twice a day;-Donepezil 10 MG tablet once a day;-Magnesium Glycinate PO 240 MG capsule once a day;-Memantine 10 MG tablet twice a day;-Nitrofurantoin 50 MG capsule once a day;-Quetiapine 50 MG tablet once a day;-Sertraline 50 MG 1 and 1/2 tablet once a day;-Vitamin C 500 MG tablet once a day; and-Trazodone 100 MG tablet once a day.However, a review of R6's MARs for April 2025 revealed the above medications were not documented as administered from April 26, 2025, to April 28, 2025. 7 . A review of R7's medical record revealed a medication list dated April 15, 2025. The medications list included the following:-Cyanocobalamin 250 MCG tablet once daily;-Aspirin 81 MG tablet once daily;-Clopidogrel/Plavix 75 MG tablet once daily; and-Sodium Chloride 1 GM tablet once daily.However, a review of R7's MARs for April 2025 revealed the above medications were not documented as administered from April 26, 2025, to April 28, 2025. 8 . A review of R8's medical record revealed a medication list dated April 15, 2025. The medications list included the following:-Donepezil HCL 10 MG 1/2 tablet once daily;-Folic Acid 1 MG tablet once daily;-Memantine 10 MG tablet twice a day;-Pantoprazole 40 MG tablet once daily; and-Trazodone 50 MG tablet once daily.However, a review of R8's MARs for April 2025 revealed the above medications were not documented as administered from April 26, 2025, to April 28, 2025. 9 . In an interview, E1 acknowledged medication was not documented as provided from April 26, 2025, to April 28, 2025, for R1, R2, R3, R4, R5, R6, R7, and R8.

Temporary Solution:

Get together with the employees from shifts for 4/26/2025 - 4/28/2025 and review residents 1 -through 8. Sign for MARs for the missing dates to be up-to-date.

Permanent Solution:

All staff was educated on the requirements of documenting when medication is given; specifically the caregiver staff on the importance of completing it on time multiple times a day and as needed. Manager and or manager designee to check MARs/ADLs binder at the end of each shift to hold each employee responsible and to ensure medication administration is being documented.

Person Responsible:

Rebeica Ratiu, Manager

Deficiency #4

Rule/Regulation Violated:

R9-10-819.A.2. Environmental Standards A. A manager shall ensure that: 2. A pest control program that complies with A.A.C. R3-8-20l(C)(4) is implemented and documented;

Evidence/Findings:

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.

Temporary Solution:

Research for a certified and professional company to come out and complete pest control.

Permanent Solution:

Program the pest control company to come out and spray of pest control and do maintenance for Five Roses Adult Care Home III as often as needed to ensure a safe environment. Advise family member to no longer spray for pest control as a professional company is in place from now on.

Person Responsible:

Rebeica Ratiu, Manager

INSP-0068988

Complete

Date: 8/3/2023

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2023-08-07

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on August 3, 2023:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
c. Documentation of:
vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8);

Evidence/Findings:

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.

Deficiency #2

Rule/Regulation Violated:

C. A manager shall ensure that a resident's medical record contains:
17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);

Evidence/Findings:

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.

Deficiency #3

Rule/Regulation Violated:

A. A manager shall ensure that:
2. If a verbal order for a resident's medication is received from a medical practitioner by the assisted living facility:
b. The verbal order is documented in the resident's medical record, and

Evidence/Findings:

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.

FIVE ROSES ADULT CARE HOME III

Facility Information

Inspection History

INSP-0129989

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0068988

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

INSP-0068987

Summary: