Inspection Reports for Lavender Fields Assisted Living

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.

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.

Complaint #28799 was investigated on 08/02/23 from 8:40 AM to 3:00 PM. The complaint was unsubstantiated but deficiencies were cited.

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.

The deficiency previously cited was corrected as of the date of this re-visit inspection.

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.

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.

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.

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.

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.

The deficiency cited in the prior annual survey was corrected as of the revisit on 02/22/21.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The survey identified deficiencies related to environmental conditions which were subsequently corrected during a follow-up visit on May 6, 2013.

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.

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.

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.

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.

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.

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.

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.