LAVENDER ADULT CARE HOME

INSP-0160788

Complete

Date: 9/30/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-10-08

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on September 30, 2025:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

R9-10-113.A.1-2. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

Evidence/Findings:

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.

Temporary Solution:

The Manager immediately scheduled and completed a TB infection control training for all current employees and volunteers. The training covered the recognition of TB signs and symptoms, infection control precautions, and reporting requirements in accordance with CDC and ADHS guidelines. Attendance sheets and training materials were added to each personnel file.

The Manager also completed the Appendix B – Tuberculosis (TB) Risk Assessment Worksheet for 2025 and filed it in the facility’s Infection Control Binder.

Permanent Solution:

The Manager and Licensee reviewed the facility’s Tuberculosis Infection Control Policy & Procedure to ensure alignment with CDC recommendations and R9-10-113 requirements. The annual TB training and risk assessment activities were added to the facility’s Infection Control and Quality Management Calendar to ensure timely completion every year.

The Manager setup digital calendar reminders to ensure that the annual TB training is provided to all staff each year on the anniversary date and that the annual TB risk assessment (Appendix B) is completed and filed by the Manager before the end of each calendar year.

Person Responsible:

Alma Hernandez, Administrator

Deficiency #2

Rule/Regulation Violated:

R9-10-808.A.3.c. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: 3. Includes the following: c The amount, type, and frequency of assisted living services and ancillary services being provided to the resident, including medication administration or assistance in the self-administration of medication;

Evidence/Findings:

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:<ul><li>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.</li><li>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.</li></ul> 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.

Temporary Solution:

The Manager immediately reviewed and revised R1’s and R2’s service plans to include the amount, type, and frequency of all assisted living services being provided. The updated service plans were reviewed with each resident (or responsible party) and signed accordingly. All other residents’ service plans were also reviewed for completeness, and any missing information regarding frequency of services was corrected.

Permanent Solution:

The Manager created The Service Plan Review Checklist and implemented to verify that every service plan includes the following before being finalized:
The type and amount of each service;
The frequency of each service; and
Signatures of both the Manager and the resident or representative.
All caregivers were retrained on documenting and reporting any changes in resident condition that could impact service plan frequency or service type.

Person Responsible:

Alma Hernandez, Administrator

Deficiency #3

Rule/Regulation Violated:

R9-10-811.C.13.a-d. Medical Records C. A manager shall ensure that a resident’s medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: a. The date and time of administration or assistance; b. The name, strength, dosage, and route of administration; c. The name and signature of the individual administering or providing assistance in the self-administration of medication; and d. An unexpected reaction the resident has to the medication;

Evidence/Findings:

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: <ul><li>“Nifedipine ER by mouth Tablet extended release 24 hour 60 mg daily PO for hypertension.” </li><li>“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.”</li></ul> 3. A review of R1’s September 2025 medication administration record (MAR) revealed the following: <ul><li>Medication was administered from September 1, 2025, to September 29, 2025.</li><li>R1’s medication did not have the dosage of each medication and the frequency of administration for each medication listed. </li><li>“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. </li><li>“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. </li></ul> 4. The Compliance Officers observed the following medication bottles:<ul><li>“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. </li><li>“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. </li></ul> 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: <ul><li>“Ativan by mouth tablet 0.5 mg PRN every 6 hours for restlessness and agitation.”</li><li>“Flomax by mouth capsule 0.4 mg at bedtime.” </li></ul> 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:<ul><li>“Lorazepam 0.5 mg Tablet Take 1 tablet by mouth every 6 hours as needed for agitation.”</li><li>“Tamsulosin HCL 0.4 mg Capsule Take 1 Capsule by mouth at bedtime for prostate.”</li></ul> 9. In an interview, E2 acknowledged that the MAR was missing dosage, frequency, and medication. In addition, E2 reported that R2 received the “Lorazepam” and “Tamsulosin.” 10. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Temporary Solution:

The Manager immediately reviewed all current medication orders, MARs, and medication packaging for accuracy and consistency. Corrections were made to reflect accurate medication names, strengths, dosages, frequencies, and routes per physician orders. Staff responsible for incomplete documentation were retrained on medication administration documentation standards.
Incident reports were completed for each documentation error and added to the Quality Management (QM) log.

Permanent Solution:

The Manager revised the Medication Administration and Documentation Policy to ensure all required data elements under R9-10-811.C.13.a–d are documented accurately on the MAR. A Medication Verification Checklist was implemented requiring the Manager to cross-check all medication orders, packaging, and MAR entries at the start of each month.
All caregivers were retrained on the proper completion of the MAR, including:
Documenting at the time of administration;
Recording exact dosage, strength, and route;
Signing each administration entry; and
Documenting any unexpected reactions immediately.
Staff competency verification forms were signed and filed in each employee’s personnel record.

Person Responsible:

Alma Hernandez, Administrator

Deficiency #4

Rule/Regulation Violated:

R9-10-817.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and

Evidence/Findings:

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: <ul><li>“Senna 8.6-50mg for Constipation.” This medication was administered from September 1, 2025, to September 29, 2025, at 8:00 am. </li><li>“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. </li></ul> 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: <ul><li>“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.” </li><li>“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.” </li></ul> 4. The Compliance Officers observed the following medication bottles:<ul><li>“Senna S” medication bottle was not available to review. </li><li>“Oxycodine Acetaminophen 5-352 mg.” </li></ul> 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: <ul><li>“Quetiapine 150 mg.” This medication was administered from September 1, 2025, to September 29, 2025, at 8:00 pm. </li><li>“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. </li></ul> 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: <ul><li>“Seroquel by mouth tablet 100mg 100 milligram at bedtime PO.” </li><li>“Lactulose 20mg/30ml 3x a day PO.” </li></ul> 9. The Compliance Officers observed the following medication bottle:<ul><li>“Quetiapine 100 mg Tab Take 1 and ½ by mouth at bedtime for sleep.” </li><li>“Lactulose 10mg/15ml take 30ml by mouth 3x a day for constipation.” </li></ul> 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.

Temporary Solution:

The Manager immediately reviewed all resident medication orders, MARs, and medication packaging to verify accuracy. MARs for R1 and R2 were corrected to reflect the proper medication names, strengths, dosages, and frequencies per prescriber orders.
Incident reports were completed for each error and filed in the facility’s Quality Management (QM) log. The caregivers responsible for the errors were retrained on the facility’s Medication Administration Policy and the requirement to verify medication labels against the MAR and physician orders prior to each administration.

Permanent Solution:

The Manager will verify all new or changed medication orders against the MAR before distribution to caregivers.
Monthly Medication Reconciliation Audits are completed by the Manager or Licensee. A Monthly Medication Reconciliation Form was created and added to the facility’s medication oversight system.
Any discrepancy between the physician order, MAR, or medication label is documented and corrected immediately, with a corresponding incident report.
All caregiving staff received refresher training on verifying and documenting medications exactly as ordered and signed competency checklists confirming understanding of proper procedure.

Person Responsible:

Alma Hernandez, Administrator

INSP-0076474

Complete

Date: 3/9/2023

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2023-03-14

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on March 9, 2023:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

G. A manager may terminate residency of a resident as follows:
1. Without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility;
2. With a 14-calendar-day written notice of termination of residency:
a. For nonpayment of fees, charges, or deposit; or
b. Under any of the conditions in subsection (C); or
3. With a 30-calendar-day written notice of termination of residency, for any other reason.

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure the policy and procedure and a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G), for one of one resident accepted by the assisted living facility on or after October 1, 2019. The deficient practice posed a health and safety risk to the residents.

Findings include:

1. Rule review of R9-10-807(G) on or after October 1, 2019 stated: "A manager may terminate residency of a resident as follows:
1. Without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility;
2. With a 14 calendar day written notice of termination of residency:
a. For nonpayment of fees, charges or deposits; or
b. Under any of the conditions in subsection (C); or
3. With a 30 calendar day written notice of termination of residency, for any other reason."
Review of subsection (C) stated: "1. The individual requires continuous:
a. Medical services;
b. Nursing services unless the assisted living facility complies with A.R.S.36-401(C); or
c. Behavioral Health Services;
2. The primary condition for which the individual needs assisted living services is a behavioral health issue;
3. The assisted living services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual;
4. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or
5. The individual requires restraints, including the use of bedrails."

2. Review of the facility's policy and procedure revealed a policy titled "Residency Agreements" that stated: "G. A manager may terminate residency of a resident as follows:
1. Without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility;
2. With a 14 calendar day written notice of termination of residency:
a. For nonpayment of fees, charges or deposits; or
b. Under any of the conditions in subsection (C); or
3. With a 30 calendar day written notice of termination of residency, for any other reason...
C. A manager shall not accept or retain an individual if:
1. The individual requires continuous:
a. Medical services;
b. Nursing services, (unless the facility complies with A.R.S.36-401(C) (ADULT FOSTER CARE HOME); or
c. Behavioral Health Services;
2. The assisted living services needed by the individual are not within the assisted living facility's scope of services;
3. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or
4. The individual requires restraints, including the use of bedrails."

3. Review of R1's medical record revealed a residency agreement. This residency agreement did not include the correct provisions allowing a manager to terminate residency of a resident. The residency agreement did not include the following term for a 14-day termination:
-The primary condition for which the individual needs assisted living services is a behavioral health issue.
Based on R1's acceptance date, this documentation was required.

4. During an interview, E1 acknowledged the facility's policy and procedure and R1's residency agreement did not include the correct policy and procedure for an assisted living facility to terminate residency.

5. Technical assistance was provided on this Rule during the compliance inspection conducted January 21, 2022.

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 documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of one resident. The deficient practice posed a potential illness risk to residents.

Findings include:

1. A.R.S. \'a7 36-406(1)(d) states "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. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director."

2. Review of R1's medical record revealed R1 refused the pneumonia vaccination January 27, 2021. However, current documentation was not available showing the pneumonia vaccination was offered or received. Based on R1's acceptance date, this documentation was required.

3. During an interview, E1 acknowledged R1's medical record did not include current documentation showing the pneumonia vaccination was offered or received.

Deficiency #3

Rule/Regulation Violated:

A. A manager shall ensure that:
2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees.

Findings include:

1. Review of the facility's policy and procedure revealed a policy titled "Emergency Action/Evacuation Plan".

2. Review of the facility documentation revealed no documentation showing this plan was reviewed every 12 months.

3. During an interview, E1 acknowledged documentation was not available showing the facility's disaster plan was reviewed within the last 12 months.

4. Technical assistance was provided on this Rule during the compliance inspection conducted January 21, 2022.

Facility Information

Inspection History

INSP-0160788

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-0076476

Summary:

INSP-0076474

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: