Lavender Adult Care Home

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a current written service plan dated September 4, 2025. This service plan indicated R1 received medication administration. 2. A review of R1’s September 2025 medication administration record (MAR) revealed the following: “Senna 8.6-50mg for Constipation.” This medication was administered from September 1, 2025, to September 29, 2025, at 8:00 am. “Oxycodine Aceta 5-352 pain.” This medication was administered from September 1, 2025, to September 29, 2025, at 8:00 am, 1:00 pm, and 7:00 pm. 3. A review of R1's medical record revealed medication orders signed and dated by a medical practitioner on September 11, 2025, for the following: “Senna S by Mouth Tablet 8.6-50mg 1 Tablet twice a day PO Give 1 tablet by mouth twice a day for bowel care.” “Oxycodine Acetaminophen by mouth tablet 5-352 mg 1 tablet twice a day PO Take 1 tablet (5mg/325mg) by mouth twice a day, scheduled for pain management.” 4. The Compliance Officers observed the following medication bottles: “Senna S” medication bottle was not available to review. “Oxycodine Acetaminophen 5-352 mg.” 5. In an interview, E2 acknowledged that the MAR had the wrong dosage for “Senna S.” E2 reported that “Senna S” was given in the morning. E2 also acknowledged the frequency for “Oxycodine Acetaminophen 5-352 mg” was incorrect and that it was administered twice a day. 6. A review of R2's medical record revealed a current written service plan dated July 4, 2025. This service plan indicated R2 received medication administration. 7. A review of R2’s September 2025 MAR revealed the following: “Quetiapine 150 mg.” This medication was administered from September 1, 2025, to September 29, 2025, at 8:00 pm. “Lactulose 10mg/15ml 3x a day.” This medication was administered from September 1, 2025, to September 29, 2025, at 8:00 am, 12:00 pm, and 5:00 pm. 8. A review of R2's medical record revealed medication orders signed and dated by a medical practitioner on September 11, 2025, for the following: “Seroquel by mouth tablet 100mg 100 milligram at bedtime PO.” “Lactulose 20mg/30ml 3x a day PO.” 9. The Compliance Officers observed the following medication bottle: “Quetiapine 100 mg Tab Take 1 and ½ by mouth at bedtime for sleep.” “Lactulose 10mg/15ml take 30ml by mouth 3x a day for constipation.” 10. In an interview, E2 reported that E2 has been administering “Seroquel” and “Lactulose” per the MAR. 11. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review, documentation review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution and annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of the facility’s September 2025 personnel schedule revealed E2 worked every day. 2. A review of E1's personnel record revealed E1’s hire date of June 28, 2021. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3. A review of E2's personnel record revealed E2’s hire date of November 8, 2020. The personnel record revealed E2's documentation of training and education related to recognizing the signs and symptoms of TB dated August 13, 2024. 4. A review of the facility’s policies and procedures revealed a policy titled “Tuberculosis Infection Control Policy & Procedure.” The policy stated, “C. Each individual who is employed by the Facility or provides volunteer services for the Facility receives annual training and education related to recognizing the signs and symptoms of tuberculosis. D. The Facility’s risk of exposure to infectious tuberculosis is assessed annually by completing the form titled “Appendix B. Tuberculosis (TB) Risk Assessment Worksheet (Appendix B)” for the facility….” 5. A review of the facility’s documentation revealed no annual assessment of the facility's TB risk assessment. 6. In an interview, E2 acknowledged that an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 7. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the frequency of assisted living services being provided to the resident, for two of two residents reviewed. The deficient practice posed a risk as the service plans did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R1's and R2's medical records revealed current service plans. However, the service plans revealed the following: R1's service plan, September 4, 2025, did not include the frequency of assistance with dressing, bathing, or showering, grooming, incontinence care, and medication administration. R2's service plan dated July 4, 2025, did not include the frequency of assistance with dressing, bathing, or showering, grooming, medication administration, and Foley catheter care. 2. In an interview, E2 acknowledged that the service plans did not include the frequency of services for R1 and R2. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident medical record contained documentation of a medication administered to a resident that included the date and time of administration; the name, strength, dosage, and route of administration; the name and signature of the individual administering the medication; and an unexpected reaction a resident had to the medication, for two of two residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1's medical record revealed a current written service plan dated September 4, 2025. This service plan indicated R1 received medication administration. 2. A review of R1's medical record revealed medication orders signed and dated by a medical practitioner on September 11, 2025, for the following: “Nifedipine ER by mouth Tablet extended release 24 hour 60 mg daily PO for hypertension.” “Ativan by mouth tablet 0.5 mg twice a day PO. Give 1 tablet by mouth at 1300 and 1 tablet by mouth at bedtime for anxiety.” 3. A review of R1’s September 2025 medication administration record (MAR) revealed the following: Medication was administered from September 1, 2025, to September 29, 2025. R1’s medication did not have the dosage of each medication and the frequency of administration for each medication listed. “Nifedipine ER 80 mg” strength does not match the order. This medication was administered from September 1, 2025, to September 29, 2025, at 8:00 am. “Lorazepam 0.05 mg anxiety” strength does not match the order. This medication was administered from September 1, 2025, to September 29, 2025, at 1:00 pm and 7:00 pm. 4. The Compliance Officers observed the following medication bottles: “Nifedipine ER 60 mg TAB Take 1 Tablet by Mouth once daily.” The medication was in a bubble packet. Several bubbles were popped for the month. “Lorazepam 0.5 mg Tablet Take 1 tablet by mouth twice daily at 1300 and 1 tablet by mouth at bedtime for anxiety.” The medication was in a bubble packet. Several bubbles were popped for the month. 5. A review of R2's medical record revealed a current written service plan dated July 4, 2025. This service plan indicated R2 received medication administration. 6. A review of R2's medical record revealed medication orders signed and dated by a medical practitioner on September 11, 2025, for the following: “Ativan by mouth tablet 0.5 mg PRN every 6 hours for restlessness and agitation.” “Flomax by mouth capsule 0.4 mg at bedtime.” 7. A review of R2’s September 2025 MAR revealed that “Ativan/Lorazepam” and “Flomax/Tamsulosin” were not documented on the MAR. 8. The Compliance Officers observed the following medication bottles: “Lorazepam 0.5 mg Tablet Take 1 tablet by mouth every 6 hours as needed for agitation.” “Tamsulosin HCL 0.4 mg Capsule Take 1 Capsule by mouth at bedtime for prostate.” 9. In an interview, E2 acknowledged that the MAR was missing dosage, frequency, and medication. In addition, E2 reported that R2 received