Five Roses Adult Care Home III.

“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 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.”

“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.”