Inspection Reports for Lavender Fields Assisted Living
150 Water St, Beverly, WV 26253, United States, WV, 26253
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 2
Dec 1, 2025
Visit Reason
The inspection was an annual environmental survey conducted to assess the facility's compliance with health, safety, maintenance, and housekeeping standards.
Findings
The licensee failed to maintain a safe, sanitary, and accident-free living environment, with specific deficiencies including dust build-up on bathroom vents and general housekeeping and maintenance issues such as carpet damage and missing bathroom fixtures.
Deficiencies (2)
| Description |
|---|
| Failure to provide maintenance and housekeeping to maintain a safe, sanitary, and accident-free living environment, including dust build-up on resident bathroom vents. |
| Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage (iron burn and bleach spots), torn chair, missing towel bar and toilet paper holder, and dirty sink. |
Report Facts
Deficiencies cited: 288
Census: 11
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 0
Dec 1, 2025
Visit Reason
The inspection was an annual environmental survey conducted to assess compliance with health and safety regulations at Lavender Fields Assisted Living.
Findings
The survey identified a total of 288 deficiencies cited during the inspection. The report does not provide detailed descriptions of individual deficiencies or severity levels.
Report Facts
Deficiencies cited: 288
Census: 11
Inspection Report
Annual Inspection
Census: 9
Deficiencies: 0
Sep 5, 2024
Visit Reason
The inspection was conducted as an annual survey of Lavender Fields Assisted Living to assess compliance with regulatory requirements.
Findings
The annual survey found no deficiencies cited during the inspection period from September 3 to September 5, 2024.
Report Facts
Census: 9
Inspection Report
Renewal
Census: 9
Deficiencies: 0
Sep 5, 2024
Visit Reason
The inspection was conducted as a license renewal survey to determine if the facility meets state requirements.
Findings
The facility was found to be in substantial compliance with state requirements based on review of documentation, staff interviews, observations, and performance testing. No deficiencies were cited during this inspection.
Report Facts
Census: 9
Inspection Report
Annual Inspection
Census: 12
Deficiencies: 4
Oct 11, 2023
Visit Reason
The inspection was conducted as an annual survey of Lavender Fields Assisted Living to assess compliance with health and safety regulations, personnel records, dietary services, and medication administration.
Findings
The facility was found deficient in maintaining complete personnel health records, specifically missing tuberculosis screening documentation and expired food handler cards. The kitchen had undated opened food items. Medication administration practices were improper, with staff initialing medication records before giving medications. Housekeeping and maintenance issues were also noted, including damaged carpet, missing bathroom fixtures, and cleanliness concerns.
Severity Breakdown
Class I: 1
Class II: 1
Class III: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Missing pre-employment and annual tuberculosis screening documentation in employee #6's personnel file. | Class III |
| Failure to put dates on opened food items and ensure all employees had current food handler cards. | Class II |
| Medication administration errors where employee #5 initialed medications as given before actual administration to resident #12. | Class I |
| Inadequate housekeeping and maintenance including damaged carpet, missing towel bars and toilet paper holders, and dirty sink. | — |
Report Facts
Census: 12
Employee identifier: 6
Employee identifier: 5
Resident identifier: 12
Deficiency completion date: Nov 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Office Manager | Interviewed regarding missing TB screening and expired food handler card | |
| Registered Nurse | Interviewed regarding medication administration errors and scheduled in-service training | |
| Employee #5 | AMAP who initialed medication records before administration | |
| Employee #6 | Employee missing TB screening and with expired food handler card |
Inspection Report
Annual Inspection
Census: 13
Deficiencies: 0
Oct 10, 2023
Visit Reason
Annual environmental inspection of Lavender Fields Assisted Living was conducted to assess compliance with health and safety regulations.
Findings
No deficiencies were cited during this annual environmental inspection. The facility was found to be in compliance with applicable standards.
Report Facts
Census: 13
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 3
Aug 2, 2023
Visit Reason
Investigation of Complaint #28799 conducted on 08/02/2023 to assess compliance with health and safety regulations and employee training requirements.
Findings
Deficiencies were cited related to failure to maintain health records of annual tuberculosis screening, lack of in-service training records on resident rights and infection control, and failure to provide annual Alzheimer's disease and dementia training. The complaint was unsubstantiated but deficiencies were noted.
Complaint Details
Complaint #28799 was investigated on 08/02/23 from 8:40 AM to 3:00 PM. The complaint was unsubstantiated but deficiencies were cited.
Severity Breakdown
Class III: 1
Class II: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to have a health record containing the results of an annual screening for tuberculosis. | Class III |
| Failed to provide and maintain a record of in-service training annually to all staff on topics including resident rights, confidentiality, abuse prevention, infection control, fire safety, and specialty care. | Class II |
| Failed to provide training to employees annually on Alzheimer's disease and related dementias and failed to maintain an employee training record. | Class II |
Report Facts
Resident census: 13
Employee identifiers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #14 | Referenced in findings for missing annual tuberculosis screening and training records. | |
| Employee #2 | Office Manager/Approved Medication Administration Personnel | Interviewed regarding missing health and training records. |
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 1
Jun 7, 2023
Visit Reason
This was the 4th re-visit to the annual survey for Lavender Fields Assisted Living to verify correction of previously cited deficiencies.
Findings
The deficiency previously cited was corrected as of the date of this re-visit inspection.
Deficiencies (1)
| Description |
|---|
| Deficiency corrected. |
Report Facts
Census: 11
Inspection Report
Re-Inspection
Census: 11
Deficiencies: 1
Apr 19, 2023
Visit Reason
The visit was a 3rd revisit to the annual survey to verify correction of previously cited deficiencies.
Findings
The licensee failed to ensure all resident care and services were provided in accordance with current standards of practice using appropriate infection control techniques, specifically a staff member was observed preparing food without a hair restraint. A plan of correction was submitted to require staff to wear hairnets in the kitchen.
Severity Breakdown
Class I: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A staff member was observed preparing breakfast in the kitchen without wearing a hair restraint, potentially affecting all residents receiving food from the facility kitchen. | Class I |
Report Facts
Census: 11
Inspection Report
Follow-Up
Census: 11
Deficiencies: 3
Dec 19, 2022
Visit Reason
This was a 1st follow-up/revisit to the annual survey conducted to verify correction of previously cited deficiencies.
Findings
The facility was found deficient in infection control practices related to staff not wearing hairnets in the kitchen, failure to document nursing progress notes after B12 injections for residents, and inadequate housekeeping and maintenance issues such as damaged carpet and missing bathroom fixtures.
Severity Breakdown
Class I: 1
Class II: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide resident care using appropriate infection control techniques; staff not wearing hairnets in kitchen. | Class I |
| Failure to ensure adequate housekeeping and maintenance, including damaged carpet, missing towel bars, and dirty sinks. | — |
| Failure to document nursing progress notes reflecting resident status after B12 injections. | Class II |
Report Facts
Census: 11
Residents receiving B12 injections: 3
Completion date for Plan of Correction: 2023.0304
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN / Director of Nursing #05 | Registered Nurse / Director of Nursing | Named in failure to document nursing notes after B12 injections. |
| RN #06 | Registered Nurse | Named in failure to document nursing notes after B12 injections. |
| Floor Aide #9 | Floor Aide | Observed not wearing hairnet in kitchen. |
| Co-owner #11 | Co-owner | Observed not wearing hairnet in kitchen and mentioned hairnets were rarely used. |
| RN #4 | Registered Nurse | Interviewed regarding nursing staff scheduling. |
| AMAP/Office Manager #02 | Office Manager | Interviewed regarding missing monthly orders for residents. |
Inspection Report
Annual Inspection
Census: 11
Deficiencies: 7
Oct 12, 2022
Visit Reason
Annual survey conducted from 10/10/22 to 10/12/22 to assess compliance with assisted living facility regulations.
Findings
The facility failed to provide scheduled activities appropriate for residents with Alzheimer's or dementia, maintain adequate housekeeping and maintenance, ensure proper infection control practices, provide whole grain foods at meals, and ensure weekly nursing visits and documentation for residents with nursing care needs. Several physical facility issues such as torn furniture and inadequate equipment maintenance were also noted.
Severity Breakdown
Class I: 1
Class II: 2
Class III: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide various types of scheduled activities appropriate for residents with Alzheimer's disease or related dementia. | — |
| Failed to ensure adequate housekeeping and maintenance, including presence of personal belongings behind furniture, carpet damage, torn furniture, missing bathroom fixtures, and unclean sink. | — |
| Failed to provide all resident care and services using appropriate infection control techniques, including staff storing drinks in resident refrigerator and not wearing hair coverings during meal prep. | Class I |
| Failed to keep interior and exterior of residence clean and in good repair, including torn couch cover and torn wheelchair arms. | — |
| Failed to adopt and follow written policy related to insulin administration requiring verification of dosage by a second staff member. | Class III |
| Failed to ensure meals contained whole grain or enriched grain foods at every meal. | Class II |
| Failed to ensure a registered nurse saw residents weekly and documented progress notes for residents with nursing care needs, including one resident receiving daily insulin injections. | Class II |
Report Facts
Census: 11
Sample Size: 3
Deficiencies cited: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #8 | Assistive Medication Administration Personnel (AMAP) | Observed assisting resident with insulin administration without second staff verification |
| Registered Nurse #6 | Registered Nurse (RN) | Interviewed regarding insulin administration policy and verification |
| Office Manager/Approved Medication Assistive Personnel (AMAP)/Office Manager #1 | Interviewed about scheduled activities and resident participation |
Inspection Report
Routine
Census: 11
Deficiencies: 1
Oct 11, 2022
Visit Reason
The inspection was conducted to assess the physical facilities and maintenance of Lavender Fields Assisted Living to ensure a safe, sanitary, and accident-free living environment.
Findings
The inspection found brown stains on the ceiling in the dining room and hallway areas, indicating maintenance issues. The Co-owner/Maintenance Director acknowledged these findings and a plan of correction involving a maintenance log and monthly walkthroughs was implemented.
Deficiencies (1)
| Description |
|---|
| Failure to maintain a safe, sanitary, and accident-free living environment as evidenced by brown stains on the ceiling in the dining room and hallway. |
Report Facts
Facility census: 11
Deficiency ID: 450
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Co-owner Maintenance Director | Verified and acknowledged maintenance findings during interview and exit interview |
Inspection Report
Follow-Up
Census: 14
Deficiencies: 0
Jan 3, 2022
Visit Reason
This was a 1st follow-up visit to the annual survey to verify correction of previously identified deficiencies.
Findings
The deficiencies identified in the prior annual survey were corrected or cleared as of this follow-up visit.
Report Facts
Census: 14
Inspection Report
Annual Inspection
Census: 12
Deficiencies: 3
Oct 8, 2021
Visit Reason
The inspection was conducted as an annual survey of Lavender Fields Assisted Living to assess compliance with health and safety regulations and facility standards.
Findings
The facility was found deficient in maintaining complete personnel health records, specifically missing tuberculosis test results for one employee, and in preparing proper transfer/discharge summaries for residents. Additionally, housekeeping and maintenance issues were noted, including damaged carpets, missing bathroom fixtures, and cleanliness concerns.
Severity Breakdown
Class III: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain a health record containing results of pre-employment tuberculosis testing for one employee. | Class III |
| Failed to prepare a summary to accompany residents on two occasions, missing required medical and service information. | — |
| Inadequate housekeeping and maintenance including damaged carpet, missing towel bars and toilet paper holders, and dirty sink. | — |
Report Facts
Facility census: 12
Employee files reviewed: 8
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #26 | Employee missing tuberculosis test in personnel records | |
| AMAP/Business Manager #23 | Approved Medication Assistive Personnel / Business Manager | Interviewed regarding missing TB test for Employee #26 |
| AMAP Registered Nurse #27 | Registered Nurse | Interviewed regarding missing transfer discharge records |
Inspection Report
Annual Inspection
Census: 12
Deficiencies: 0
Oct 6, 2021
Visit Reason
Annual environmental inspection of Lavender Fields Assisted Living conducted on October 6, 2021.
Findings
No deficiencies were cited during this annual environmental inspection.
Report Facts
Census: 12
Inspection Report
Annual Inspection
Census: 14
Deficiencies: 1
Feb 22, 2021
Visit Reason
This document is a 2nd revisit to the annual survey conducted to verify correction of previously cited deficiencies at Lavender Fields Assisted Living.
Findings
The deficiency cited in the prior annual survey was corrected as of the revisit on 02/22/21.
Deficiencies (1)
| Description |
|---|
| Deficiency corrected from prior annual survey |
Report Facts
Census: 14
Inspection Report
Routine
Census: 14
Deficiencies: 0
Jan 20, 2021
Visit Reason
Routine infection control inspection of Lavender Fields Assisted Living was conducted on January 20, 2021.
Findings
No citations were issued during the inspection. The visit was completed without any deficiencies noted.
Report Facts
Census: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Marks | Office Manager | Present at exit of inspection |
| Traci Roy | RN | Present at exit of inspection |
Inspection Report
Re-Inspection
Census: 14
Deficiencies: 2
Jan 20, 2021
Visit Reason
The visit was a re-inspection to verify correction of previous deficiencies related to nursing documentation and facility environment.
Findings
The facility failed to ensure the Registered Nurse maintained complete visit records including date, time in/out, duties performed, concerns, and signature. Deficiencies in housekeeping and maintenance were also noted, including damaged carpet and missing bathroom fixtures. A plan of correction was implemented on January 20, 2021.
Severity Breakdown
Class III: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Registered Nurse failed to maintain a record with date, time in/out, duties performed, concerns, and signature for each visit. | Class III |
| Inadequate housekeeping and maintenance including damaged carpet, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Census: 14
Sample Size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #26 | Registered Nurse | Named in nursing documentation deficiency |
Inspection Report
Annual Inspection
Census: 14
Deficiencies: 8
Oct 12, 2020
Visit Reason
Annual survey conducted to assess compliance with state regulations for assisted living facilities, including health and safety, medication administration, infection control, employee screening, and physical environment.
Findings
The facility was found deficient in multiple areas including failure to provide a complete monthly activity calendar, inadequate housekeeping and maintenance, incomplete medication assistive personnel retraining documentation, lack of employee clearance documentation, failure to enforce mask-wearing during COVID-19, incomplete resident health assessments, incomplete nursing documentation, and unsanitary kitchen conditions.
Severity Breakdown
Class I: 3
Class II: 2
Class III: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide a monthly calendar listing type, time, and duration of all social and recreational activities and documentation of whether activities took place for all residents. | Class III |
| Failed to ensure adequate housekeeping and maintenance, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink. | — |
| Failed to ensure medication assistive personnel (AMAP) files contained required retraining documentation and quarterly observations. | Class I |
| Failed to ensure all employees had West Virginia Clearance for Access: Registry and Employment Screening Act documentation. | Class II |
| Failed to enforce mask-wearing policy for staff during COVID-19 pandemic, resulting in immediate and serious threat to residents. | Class I |
| Failed to have signed and dated health assessments by licensed health care professionals within required timeframes for residents. | Class II |
| Failed to maintain nursing records with date, time in/out, duties performed, concerns, and complete signatures for registered nurse visits. | Class III |
| Failed to maintain a safe, sanitary, and accident-free living environment, including presence of hard, uneaten donuts in kitchen and dirty microwave. | Class I |
Report Facts
Resident count: 14
Residents affected: 14
AMAP employees reviewed: 5
Employee records reviewed: 8
Residents with incomplete health assessments: 2
Days late: 21
Days late: 47
Dates of survey: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator #01 | Administrator and part owner | Named in findings related to employee clearance and mask-wearing enforcement |
| RN #02 | Registered Nurse | Named in findings related to medication assistive personnel retraining oversight and nursing documentation |
| RN #03 | Registered Nurse | Named in findings related to nursing documentation and health assessment delays |
| AMAP #04 | Approved Medication Assistive Personnel | Named in findings related to missing retraining documentation and mask-wearing |
| AMAP #05 | Approved Medication Assistive Personnel | Named in findings related to missing retraining verification and mask-wearing |
Inspection Report
Annual Inspection
Census: 16
Deficiencies: 0
Jun 24, 2020
Visit Reason
Annual environmental inspection conducted to assess compliance with health and safety regulations at Lavender Fields Assisted Living.
Findings
No deficiencies were cited during the inspection, indicating compliance with applicable standards.
Report Facts
Census: 16
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 0
Jun 5, 2019
Visit Reason
The visit was conducted as an annual licensure survey and environmental inspection of Lavender Fields Assisted Living.
Findings
No deficiencies were cited during the annual licensure survey. The facility had no recommendations from the Fire Marshal or Sanitarian reports.
Report Facts
Census: 8
Date of Fire Marshal report: Jan 9, 2019
Sanitarian Date: Apr 29, 2019
Inspection Report
Annual Inspection
Census: 13
Deficiencies: 0
Jun 5, 2019
Visit Reason
The visit was conducted as an annual licensure survey of Lavender Fields Assisted Living.
Findings
No deficiencies were cited during the annual licensure survey conducted from June 3-5, 2019.
Report Facts
Census: 13
Inspection Report
Annual Inspection
Census: 15
Deficiencies: 0
Jun 27, 2018
Visit Reason
The visit was conducted as an annual licensure survey for Lavender Fields Assisted Living.
Findings
No deficiencies were cited during the annual licensure survey conducted from June 25-27, 2018.
Report Facts
Census: 15
Inspection Report
Annual Inspection
Census: 14
Deficiencies: 0
Jun 4, 2018
Visit Reason
The visit was conducted as an annual licensure survey of Lavender Fields Assisted Living to assess environmental and regulatory compliance.
Findings
No deficiencies were cited during this annual licensure survey, indicating compliance with applicable standards at the time of inspection.
Report Facts
Census: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenny Sartin | Health Facility Surveyor II | Surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 7
Deficiencies: 0
Jun 21, 2017
Visit Reason
The visit was conducted as an annual licensure survey of Lavender Fields Assisted Living.
Findings
The annual licensure survey found no deficiencies at the facility during the inspection conducted June 19-21, 2017.
Report Facts
Deficiencies cited: 0
Inspection Report
Annual Inspection
Census: 7
Deficiencies: 0
Jun 7, 2017
Visit Reason
The visit was conducted as an annual licensure survey for Lavender Fields Assisted Living to assess environmental conditions and compliance with regulatory standards.
Findings
No deficiencies were cited during this annual licensure survey. The facility was found to be in compliance with the applicable standards at the time of inspection.
Report Facts
Census: 7
Inspection Report
Annual Inspection
Census: 9
Deficiencies: 0
Aug 1, 2016
Visit Reason
The inspection was conducted as an annual licensure survey and a follow-up survey to assess compliance with regulatory requirements.
Findings
The report documents the annual licensure survey conducted June 7-10, 2016, and a follow-up survey on August 1, 2016, with census counts of 10 and 9 respectively. Specific deficiencies or findings are not detailed in the provided text.
Report Facts
Census during annual survey: 10
Census during follow-up survey: 9
Inspection Report
Annual Inspection
Census: 10
Deficiencies: 1
Jun 10, 2016
Visit Reason
The inspection was conducted as an annual licensure survey of Lavender Fields Assisted Living to assess compliance with personnel record requirements and other regulatory standards.
Findings
The survey found deficiencies related to personnel records, specifically failure to ensure timely tuberculosis (TB) screening for new employees. Additional observations from a prior behavioral health survey in 2004 noted safety and housekeeping issues in the adolescent residence.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a screening for tuberculosis (TB) was completed for two of five employees (#9 and #11) prior to employment. |
Report Facts
Census: 10
Employees without timely TB screening: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #9 | Hired November 2, 2015; TB screening completed June 7, 2016. | |
| Employee #11 | Hired May 3, 2016; TB screening completed June 2, 2016. |
Inspection Report
Annual Inspection
Census: 9
Deficiencies: 2
Jun 6, 2016
Visit Reason
The visit was conducted as an annual licensure survey to assess environmental compliance and disaster and emergency preparedness at Lavender Fields Assisted Living.
Findings
The facility was found deficient for failing to review and update the disaster and emergency preparedness plan annually and for not conducting annual disaster and emergency preparedness drills with all staff shifts. Environmental deficiencies were cited but not detailed in this report.
Severity Breakdown
CLASS III: 1
CLASS I: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to review and update the disaster and emergency preparedness plan on an annual basis and sign and date the plan to verify review. | CLASS III |
| Failure to rehearse the disaster and emergency preparedness plan with all staff from each shift annually and maintain documentation of the rehearsal. | CLASS I |
Report Facts
Deficiencies cited: 2
Census: 9
Inspection Report
Census: 6
Deficiencies: 0
Nov 3, 2015
Visit Reason
The inspection was conducted as a Change of Ownership (CHOW) survey with entrance and exit on 09/10/15.
Findings
The report documents the Change of Ownership survey with a census of six residents. No specific deficiencies or severity levels are detailed in the report.
Report Facts
Census: 6
Inspection Report
Census: 6
Deficiencies: 0
Sep 15, 2015
Visit Reason
The inspection was conducted as a Change of Ownership (CHOW) survey on September 14-15, 2015.
Findings
The report documents the Change of Ownership survey with a census of 6 residents. No specific deficiencies or findings are detailed in this report.
Report Facts
Census: 6
Inspection Report
Change Of Ownership
Census: 6
Deficiencies: 1
Sep 10, 2015
Visit Reason
The survey was conducted as a Change of Ownership (CHOW) inspection to assess compliance with physical facility requirements and safety standards at Lavender Fields Assisted Living.
Findings
The inspection found that the exterior exit egress of the residence was not in good repair, specifically noting a wooden exit ramp with a lowered edge creating a potential trip hazard.
Severity Breakdown
CLASS II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The wooden exit ramp leading from the hallway for bedrooms 1 to 5 has a lowered edge of approximately 1 1/4 inch where it abuts the wooden porch, creating a potential trip hazard. | CLASS II |
Report Facts
Census: 6
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 2
Mar 19, 2015
Visit Reason
The visit was conducted as an annual licensure survey to assess compliance with health and safety regulations and physical facility standards at Lavender Fields Assisted Living.
Findings
The inspection found deficiencies related to physical facilities, including three resident bedroom doors that would not latch properly and a hole in the ceiling of the ADA shower stall. The licensee failed to keep the interior of the residence in good repair.
Deficiencies (2)
| Description |
|---|
| Three resident bedroom doors (Bedroom #3, #6, and #10) will not latch when closed. |
| Hole in the ceiling above the ADA shower stall in the resident bathroom. |
Report Facts
Census: 7
Total Capacity: 10
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Hammons | AMAP staff | Staff present during the tour and acknowledged deficiencies |
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 2
Mar 19, 2015
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with health and safety regulations and physical facility standards.
Findings
The facility was found deficient in maintaining the interior of the residence in good repair, including three resident bedroom doors that would not latch and a hole in the ceiling of the ADA shower stall. Repairs were planned and completed by June 9, 2015.
Deficiencies (2)
| Description |
|---|
| Three resident bedroom doors (#3, #6, and #10) will not latch when closed. |
| Hole in the ceiling above the ADA shower stall in the resident bathroom. |
Report Facts
Census: 7
Total Capacity: 10
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Hammons | AMAP staff | Staff present during the tour and acknowledged deficiencies |
Inspection Report
Annual Inspection
Census: 6
Deficiencies: 5
Mar 3, 2015
Visit Reason
Annual licensure survey conducted to assess compliance with health, safety, staffing, personnel records, dietary services, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to submit required abuse registry screenings prior to hire, inadequate CPR/First Aid certification for staff, failure to maintain timely tuberculosis screenings, and failure to weigh residents monthly as required. Additionally, housekeeping and maintenance issues were observed, such as damaged carpet, missing bathroom fixtures, and unclean conditions.
Severity Breakdown
Class I: 1
Class II: 1
Class III: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to submit required information for central abuse registry screening prior to hire for four employees and failure to check nurse aide abuse registry prior to hire for one employee. | Class II |
| Failure to ensure one employee with current first aid and CPR training on duty at all times; CPR training conducted by an uncertified instructor and no official CPR cards available. | Class I |
| Failure to maintain confidential personnel records including pre-employment and annual tuberculosis screening prior to hire for four employees. | — |
| Failure to weigh residents monthly as required for five residents. | Class III |
| Inadequate housekeeping and maintenance including iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Employees without timely abuse registry screening: 4
Employees with delayed abuse registry screening: 4
Shifts worked alone without current CPR/First Aid training: 61
Residents not weighed monthly: 5
Weight measurement delays: 30
Inspection Report
Annual Inspection
Census: 4
Deficiencies: 0
Apr 1, 2014
Visit Reason
The visit was conducted as an annual licensure survey of Lavender Fields Assisted Living to assess compliance with regulatory requirements.
Findings
The report documents the annual licensure survey conducted from March 31 to April 1, 2014, with a census of 4 residents. No specific deficiencies or severity levels are detailed in the report.
Report Facts
Census: 4
Inspection Report
Annual Inspection
Census: 5
Deficiencies: 3
Mar 5, 2014
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with health, safety, disaster preparedness, and physical facility regulations.
Findings
The facility was found deficient in maintaining and reviewing its disaster and emergency preparedness plans annually, ensuring adequate maintenance and housekeeping for a safe and sanitary environment, and addressing physical facility issues such as non-functioning exit lights, alarm system trouble signals, and outdated sprinkler system certification.
Severity Breakdown
Class I: 2
Class III: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to review and update the disaster and emergency preparedness plan annually with signatures verifying review. | Class III |
| Failure to rehearse the disaster and emergency preparedness plan annually with all staff and maintain documentation of the rehearsal. | Class I |
| Failure to provide maintenance and housekeeping to maintain a safe, sanitary, and accident-free living environment, including issues with GFI receptacle, exit/emergency lights, fire alarm system trouble signal, and outdated sprinkler system certification. | Class I |
Report Facts
Deficiencies cited: 3
Census: 5
Date of Completion: May 5, 2014
Sprinkler system certification date: 2012
Inspection Report
Follow-Up
Census: 5
Deficiencies: 0
May 29, 2013
Visit Reason
The visit was a follow-up survey to verify correction of previously cited deficiencies from the annual licensure survey conducted in March 2003.
Findings
The follow-up survey found that the deficiencies cited in the prior annual licensure survey were corrected.
Report Facts
Census: 5
Census: 7
Inspection Report
Annual Inspection
Census: 7
Deficiencies: 6
Mar 27, 2013
Visit Reason
Annual licensure survey conducted to assess compliance with health and safety regulations, staffing requirements, health care standards, and infection control practices at Lavender Fields Assisted Living.
Findings
The facility was found deficient in multiple areas including failure to submit required central abuse registry screenings prior to hiring, lack of current CPR and first aid training documentation for employees, incomplete resident health assessments within required timeframes, inadequate housekeeping and maintenance, failure to ensure medications were administered by appropriately licensed personnel, and poor infection control practices during a communicable disease outbreak.
Severity Breakdown
Class I: 3
Class II: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to submit required information for central abuse registry screening and maintain documentation prior to hiring for five employees. | Class II |
| Failed to ensure one employee on duty at all times had current first aid and CPR training for six employees. | Class I |
| Failed to complete signed and dated health assessments by a licensed health care professional within required timeframes for two residents. | Class II |
| Failed to ensure resident care and medication administration by appropriately licensed health care professionals; issues with documentation and training of approved medication assistive personnel. | Class I |
| Failed to provide resident care and services in accordance with infection control standards during a communicable disease outbreak, including lack of precautions, inadequate cleaning, and improper handling of personal items. | Class I |
| Failed to maintain adequate housekeeping and maintenance, including presence of personal belongings in inappropriate places, damaged carpet, missing bathroom fixtures, and dirty sink. | — |
Report Facts
Employees with late abuse registry checks: 5
Employees lacking current CPR/first aid training: 6
Residents with late health assessments: 2
Residents affected by communicable disease: 7
Census: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| KB | Activity Director | Named in deficiency for late central abuse registry screening. |
| AS | Aide | Named in deficiency for late central abuse registry screening. |
| DW | Aide/Approved Medication Assistive Personnel (AMAP) and RN | Named in deficiencies for late central abuse registry screening and medication administration documentation. |
| AC | Aide/AMAP | Named in deficiency for late central abuse registry screening. |
| RT | Licensee | Interviewed regarding infection control and training documentation. |
| CA | Approved Medication Assistive Personnel (AMAP) | Interviewed regarding infection control practices. |
| SF | Nurse | Mentioned in relation to resident illness assessment. |
| KW | AMAP | Named in deficiency for lack of documentation as AMAP and training. |
| DH | AMAP | Named in deficiency for lack of training documentation. |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 4
Mar 4, 2013
Visit Reason
The inspection was conducted as an annual licensure survey to assess environmental conditions and compliance with physical facility regulations.
Findings
The licensee failed to maintain the interior and exterior of the residence in a clean and good repair condition. Specific issues included snow accumulation on exit ramps, cuts in the bathroom floor, a non-working bathroom fan, and a dirty portable fan in the kitchen area.
Deficiencies (4)
| Description |
|---|
| Snow accumulation of one inch on exit ramps and walkways, obstructing a free and clear pathway. |
| Several cuts in the bathroom floor (12 by 2 inches, rectangular), making cleaning and sanitizing difficult and potentially weakening the floor structure. |
| Non-working fan in the bathroom. |
| Portable desk fan in the kitchen with grey debris blowing air toward the cooking area. |
Report Facts
Census: 8
Snow depth: 1
Floor cut dimensions: 12
Floor cut dimensions: 2
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 1
Mar 4, 2013
Visit Reason
Annual licensure survey conducted to assess environmental conditions and compliance of Lavender Fields Assisted Living facility.
Findings
The survey identified deficiencies related to environmental conditions which were subsequently corrected during a follow-up visit on May 6, 2013.
Deficiencies (1)
| Description |
|---|
| Environmental deficiencies noted during the annual licensure survey. |
Report Facts
Census: 8
Census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sharron Ball | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 0
Feb 22, 2012
Visit Reason
The visit was conducted as an annual licensure survey of Lavender Fields Assisted Living to assess compliance with regulatory requirements.
Findings
No deficiencies were cited during the survey, and technical assistance was provided to the facility.
Report Facts
Census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Surveyor during the annual licensure survey |
| Louise Hall | RN, HFNS II | Surveyor during the annual licensure survey |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 0
Feb 22, 2012
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory requirements for Lavender Fields Assisted Living.
Findings
No deficiencies were cited during the survey. Technical assistance was provided to the facility.
Report Facts
Census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rick Adkins | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 7
Deficiencies: 0
Mar 8, 2011
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory requirements for Lavender Fields Assisted Living.
Findings
No deficiencies were cited during the survey. Technical assistance was provided to the facility.
Report Facts
Census: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 7
Deficiencies: 0
Feb 23, 2011
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory requirements for Lavender Fields Assisted Living.
Findings
No deficiencies were cited during the survey. Technical assistance was provided to the facility.
Report Facts
Census: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Surveyor |
| Louise Hall | RN, HFNS II | Surveyor |
Inspection Report
Follow-Up
Census: 9
Deficiencies: 0
Mar 8, 2010
Visit Reason
This was a first follow-up visit to the annual licensure survey conducted on February 2-3, 2010, to verify compliance and correction of any deficiencies.
Findings
The report documents the follow-up to the annual licensure survey for Lavender Fields Assisted Living. No specific deficiencies or findings are detailed in this follow-up report.
Report Facts
Census at annual survey: 10
Census at follow-up survey: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Surveyor during the annual licensure survey |
| Louise Hall | RN, HFNS II | Surveyor during both the annual licensure survey and the follow-up survey |
Inspection Report
Annual Inspection
Census: 9
Deficiencies: 0
Feb 17, 2010
Visit Reason
The visit was conducted as an annual licensure survey of Lavender Fields Assisted Living to assess compliance with regulatory requirements.
Findings
No deficiencies were cited during the survey, but technical assistance was provided to the facility.
Report Facts
Census: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason T. Lintner | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 10
Deficiencies: 6
Feb 3, 2010
Visit Reason
The annual licensure survey was conducted to assess compliance with health and safety regulations, staffing requirements, medication administration, physical facilities, and other regulatory standards at Lavender Fields Assisted Living.
Findings
The inspection identified multiple deficiencies including failure to ensure staff had current CPR training, inadequate medication labeling and administration practices, lack of resident identification on medication records, inadequate housekeeping and maintenance, and improper storage of toxic or hazardous materials.
Severity Breakdown
Class I: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure one employee with current CPR training is on duty at all times. | Class I |
| Failure to maintain a safe and appropriate environment for consumers (from earlier behavioral health survey). | — |
| Inadequate housekeeping and maintenance including damaged carpet, missing bathroom fixtures, and unclean sink. | — |
| Failure to assure medications are administered as required and failure to maintain picture identification on Medication Administration Records. | Class I |
| Failure to store medications in original pharmacy labeled containers. | Class I |
| Failure to store toxic or hazardous materials in locked storage. | Class I |
Report Facts
Census: 10
Partial shifts staffed without current CPR certification: 50
Shifts staffed without current CPR certification: 32
Medication Administration Records without resident identification: 5
Residents able to ambulate independently and confused: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rhonda Talbott | Owner | Responsible for overseeing CPR/FA training and medication administration corrections |
| Jane Cost | RN, HFNS II | Surveyor |
| Louise Hall | RN, HFNS II | Surveyor |
| TT | Approved Medication Assistive Personnel | Observed administering unlabeled medication |
| RT | Owner who provided statements about expired CPR certifications and medication issues |
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 0
Aug 10, 2009
Visit Reason
The inspection was conducted as a complaint investigation related to two complaint investigations numbered #4996 and #5002, with a follow-up visit to verify correction of deficiencies.
Findings
The initial complaint investigations identified deficiencies which were followed up on August 11, 2009, at which time all deficiencies were corrected.
Complaint Details
Complaint investigations #4996 and #5002 were conducted on June 8 and June 15, 2009, respectively, with a census of 9. A follow-up visit on August 11, 2009, confirmed all deficiencies were corrected.
Report Facts
Census: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Surveyor involved in complaint investigations and follow-up |
| Louise Hall | RN HFNS II | Surveyor involved in complaint investigations and follow-up |
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 3
Jun 15, 2009
Visit Reason
The inspection was conducted as a complaint investigation (#4996) regarding the facility's failure to report a major incident involving medication theft and concerns about medication security and administration.
Findings
The facility failed to report a major incident involving the theft of morphine pills by an employee. Additionally, the medication cart was found unlocked and unattended, leaving medications accessible to residents and visitors. The facility also failed to ensure Schedule II medications were double locked as required.
Complaint Details
Complaint #4996 involved failure to report a major incident where an aide took twenty-two morphine pills from a resident. The complaint was substantiated by observations and interviews conducted on June 8, 2009.
Severity Breakdown
Class I: 2
Class III: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report a major incident to the licensing agency as required. | Class III |
| Medication cart was unlocked and unattended, making medications accessible to residents and visitors. | Class I |
| Schedule II medications were not secured with two separate locks as required. | Class I |
Report Facts
Morphine pills stolen: 22
Residents present: 9
Completion date for inservice: Jul 13, 2009
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BL | Approved Medication Administration Personnel (AMAP) | Named in medication security deficiency; acknowledged leaving medication cart unlocked. |
| PK | Aide/Cook | Interviewed regarding medication cart being unattended. |
| Administrator | Failed to report major incident and acknowledged medication cart security issues. | |
| Supervising Registered Nurse | Acknowledged medication cart security issues and responsible for conducting inservice. |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 0
Mar 10, 2009
Visit Reason
Annual licensure survey conducted to assess the environment and compliance of Lavender Fields Assisted Living.
Findings
No deficiencies or technical assistance were identified during the annual licensure survey.
Report Facts
Census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Named as surveyor conducting the annual licensure survey |
| Jason Lintner | Surveyor | Named as surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 0
Feb 23, 2009
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory requirements for Lavender Fields Assisted Living.
Findings
No deficiencies were found during the survey. Technical assistance was provided to the facility.
Report Facts
Census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Surveyor |
| Louise Hall | RN, HFNS II | Surveyor |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 0
Apr 10, 2008
Visit Reason
The visit was conducted as an annual licensure survey to assess environmental conditions and compliance at Lavender Fields Assisted Living.
Findings
The survey found no deficiencies during the annual licensure inspection.
Report Facts
Census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Garry Taylor | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 5
Mar 5, 2008
Visit Reason
Annual licensure survey conducted to assess compliance with health and safety regulations, employee training, personnel records, and medication administration standards at Lavender Fields Assisted Living.
Findings
The survey identified multiple deficiencies including inadequate employee training on specialty care needs, failure to complete pre-employment tuberculosis screening, improper medication administration by Approved Medication Assistive Personnel (AMAP), and inadequate housekeeping and maintenance issues such as damaged carpets and missing bathroom fixtures.
Severity Breakdown
Class I: 1
Class II: 2
Class III: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure new employees receive training on specialty care based on individualized resident needs. | Class II |
| Failure to ensure tenured employees receive annual training on specialty care based on individualized resident needs. | Class II |
| Failure to ensure pre-employment tuberculosis screening is completed prior to employment. | Class III |
| Failure to assure medications administered by AMAP are given as required by regulations, including improper medication administration and lack of hand hygiene. | Class I |
| Failure to ensure adequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and dirty sinks. | — |
Report Facts
Census: 8
Personnel files reviewed: 6
Medication administration observations: 2
Completion date for carpet replacement: Sep 30, 2004
Plan of correction completion dates: May 5, 2008
Plan of correction completion date for medication retraining: Apr 10, 2008
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Surveyor |
| Betty Marine | LSW HFS II | Surveyor |
| Rhonda Talbott | Responsible for monitoring employee training and personnel record corrections | |
| Debbie White | RN | Supervising nurse involved in medication administration findings and monitoring training and personnel record corrections |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 0
Mar 5, 2008
Visit Reason
The inspection was conducted as an annual licensure survey of Lavender Fields Assisted Living to assess compliance with regulatory requirements.
Findings
The report indicates that deficiencies identified during the annual survey were subsequently corrected by the first follow-up visit on May 5, 2008.
Report Facts
Census: 8
Census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Surveyor for both the annual licensure survey and the follow-up survey |
| Betty Marine | LSW HFS II | Surveyor for the annual licensure survey |
| Louise Hall | RN HFNS II | Surveyor for the follow-up survey |
Inspection Report
Follow-Up
Census: 7
Deficiencies: 0
Jun 20, 2007
Visit Reason
The visit was a follow-up survey to verify correction of deficiencies identified during the initial licensure survey conducted on May 2, 2007.
Findings
The follow-up survey found that deficiencies identified during the initial licensure survey were corrected, and technical assistance was provided.
Report Facts
Census: 4
Census: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Surveyor for initial licensure and follow-up surveys |
| Louise Hall | RN, HFNS II | Surveyor for initial licensure and follow-up surveys |
| Deborah Dodrill | HFS II | Surveyor for follow-up survey |
Inspection Report
Follow-Up
Census: 6
Deficiencies: 3
May 17, 2007
Visit Reason
The visit was a follow-up survey to verify correction of previous deficiencies identified during the initial environmental survey and licensure survey.
Findings
The facility had several deficiencies related to physical environment, housekeeping, maintenance, and hot water temperature. Some deficiencies were repeated but corrective actions such as relocating handicapped parking, adding handrails, replacing carpet, and adjusting hot water temperature were completed or in progress by the specified completion dates.
Severity Breakdown
Class I: 1
Class II: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Handicapped parking space not on level area; no accessible walk or access aisle from handicapped parking to porch; handrails missing on ramp at back of residence; steps missing from courtyard to lawn; landings missing for doors from impractical rooms. | Class I |
| Hot water temperatures not maintained between 105°F and 115°F, measured at 100°F initially and dropping quickly, causing uncomfortable bathing temperatures. | Class II |
| Inadequate housekeeping and maintenance including personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Census: 6
Completion date: May 17, 2007
Completion date: Jun 1, 2007
Completion date: Sep 30, 2004
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Garry Taylor | Named in relation to initial licensure survey and follow-up environmental survey |
Inspection Report
Routine
Census: 4
Deficiencies: 3
May 2, 2007
Visit Reason
The inspection was a routine survey conducted to assess compliance with health care standards and licensing regulations at Lavender Fields Assisted Living.
Findings
The facility was found deficient in ensuring proper transfer documentation for residents, medication administration according to physician orders, and maintaining adequate housekeeping and maintenance. Specific issues included missing transfer summaries, medication errors, and physical environment concerns such as damaged carpet and missing bathroom fixtures.
Severity Breakdown
Class I: 1
Class II: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure a summary of information accompanies a resident at the time of transfer or discharge. | Class II |
| Failure to ensure medications are administered according to physician orders, including missed doses and incorrect medication documentation. | Class I |
| Failure to ensure adequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and unclean sink. | — |
Report Facts
Census: 4
Deficiencies cited: 3
Medication doses missed: 3
Residents reviewed: 4
Residents with medication errors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Named in initial comments as part of facility staff |
| Louise Hall | RN, HFNS II | Named in initial comments as part of facility staff |
| Rhonda Talbott | Named as monitor for transfer form deficiency | |
| Debbie White | RN | Named as monitor for medication administration deficiency and involved in training |
Inspection Report
Original Licensing
Census: 1
Deficiencies: 6
Mar 5, 2007
Visit Reason
The inspection was conducted as an initial licensure survey of Lavender Fields Assisted Living to assess compliance with physical facilities and environmental requirements.
Findings
The survey found deficiencies including non-compliance with physical facilities requirements such as improper handicapped parking placement, lack of accessible walkways, missing handrails and steps, inadequate landings for certain rooms, and hot water temperatures below the required range. The administrator failed to assure compliance with Subsection 4.12 of the licensure rule.
Severity Breakdown
CLASS I: 5
CLASS II: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| The handicapped parking space must be relocated to a level area in the parking lot. | CLASS I |
| A handicapped accessible walk or access isle is not provided from the handicapped parking space to the porch. | CLASS I |
| Handrails are not provided for the ramp on the back side of the residence. | CLASS I |
| Steps are not provided from the court yard area to the outside lawn space. | CLASS I |
| Landings at least as wide as the door width are not provided for the doors leading to the outside from the four impractical rooms. | CLASS I |
| Hot water temperature being delivered in resident areas measured 100 degrees Fahrenheit, below the required 105-115 degrees. | CLASS II |
Report Facts
Census: 1
Completion date for corrections: May 5, 2007
Hot water temperature measured: 100
Hot water temperature corrected to: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Garry Taylor | Named in relation to the initial licensure survey |
Inspection Report
Original Licensing
Census: 1
Deficiencies: 0
Mar 5, 2007
Visit Reason
Initial licensure survey conducted to assess the environment and compliance of Lavender Fields Assisted Living.
Findings
The initial licensure survey identified deficiencies related to the environment. Follow-up surveys were conducted to verify correction of deficiencies, which were subsequently corrected.
Report Facts
Census: 1
Census: 6
Census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Garry Taylor | Surveyor | Conducted initial licensure and follow-up surveys |
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