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32 | Allegation: Staff do not ensure fire drills are being conducted as required
LPA obtained the fire drill logs from the facility indicating that the facility is conducting monthly fire drills with staff and rotating shifts each month. Facility also provided LPA with documentation that the facility held an in-service training on April 14, 2026 for emergency disaster preparedness. According to fire alarm company invoice, a service was provided on April 8, 2026 to ensure all alarms are functioning properly. Staff interviews indicated that they have participated in fire drills.
Allegation: Staff do not ensure food is kept at the required temperature
On March 12, 2026, LPA toured the kitchen area with the Regional Director of Operations (RDO). LPA observed that the freezer was within regulatory range at -17 degrees F and the refrigerator was within range at 39 degrees F. Interviews with staff indicated that they have never observed food being kept out of the required temperature range.
Allegation: Staff do not ensure kitchen equipment is clean and sanitary
During the tour of the kitchen on March 12, 2026, LPA observed the kitchen equipment was clean and sanitary. Interviews with staff (S1, S2, S3, S4, and S5) indicated that they have never observed the kitchen not being cleaned and sanitized, including equipment. Staff indicated that ensuring cleanliness in the kitchen is a part of their job while working in the kitchen and that cleaning/sanitizing is done regularly. Staff also indicated that dishes are sanitized and that the dishwasher water runs hot at the correct temperature to clean the dishes. LPA observed that the water to sanitize the dishes was within the regulatory range at 172 degrees F.
Allegation: Facility is not ensuring volunteers are criminal record cleared
Interview with the former Executive Director (ED), Kay Devault, indicated that they never had anyone working at the care home, including family, that were not criminal record cleared. Interviews with multiple staff indicated that they have never witnessed the former ED’s spouse working at the care home as a volunteer.
Based on observations, interviews conducted, and documentation obtained although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided. |