In another memo dated 6/17/21 to residents, the facility re-iterates that transportation for medical appointments “are to be scheduled for Tuesdays and Thursdays only…If you have a medical appointment for any reason on a Monday, Wednesday, or Friday, it will be on an availability basis only and there is a charge of $35.”

The facility’s Plan of Operation under Transportation Program states: 1) Establish a regular bus route based on the needs and requests of the residents. 2) Make available a regular bus route Monday through Friday. This bus route may include (but is not limited to) stops at: Local Banks, Grocery Stores, Doctor’s Offices, Shopping Centers or Mall, and Senior Citizen’s Center. Additionally, the procedure listed for medical appointments states “Should the resident not have transportation, the community arranges for necessary transportation.” In the section Basic Services under Transportation, “The community will arrange and/or provide transportation to scheduled medical and dental appointments, shopping, dining and specified community events in a 25-mile radius. Transportation is available from 8 a.m. to 5 p.m. on designated days.”

In the facility’s admission agreement, it states “We will make available to residents, or otherwise assure the provision of, scheduled transportation to the nearest appropriate health facilities for medical and dental appointments, social services agencies, shopping and recreational facilities within a 12-mile radius. Transportation is available from 8:30 a.m. to 3:30 p.m., on designated days. Other transportation outside normal business hours may be arranged by the Resident with the Community’s Activities Director for an additional charge, or with an outside agency.

Continued on 9099-C

On 3/14/22 at 11:38 am, LPA spoke with Resident #1 (R1). R1 states that R1 schedules medical appointments, and then requests transportation with the facility. R1 states that on more than one occasion, R1 has not been able to get transportation needs met. R1 says the facility offers another day, besides Tuesday or Thursday, and that R1 will be charged.

Based on the evidence obtained, the allegation “Facility did not arrange transportation for residents” is deemed Substantiated. The facility is not providing basic transportation services to residents in care.

On the allegation “Kitchen does not meet standards for food storage, cleanliness, and repair,” the complainant’s concern was that the facility kitchen had encrusted dirt on the floor, equipment in disrepair, and open food containers in the kitchen and freezer. To investigate the allegation, LPA interviewed the complainant, toured the kitchen and dining room, interviewed the Business Office Manager (BOM) and credible witness, and reviewed photos obtained.

On 7/29/21 at 2:41 pm, LPA toured the kitchen and dining room. During the facility tour, LPA observed a kitchen floor with food in several areas, a stained, dirty stove, backsplash, and sidewall, the stove’s foot propped with cardboard, two uncovered trashcans, dirty dishes in the sink and on the counters, a chopping board on the counter that had been used and not cleaned, and soiled utensils on the counter. Additionally, LPA observed a bag of perishable food on the counter unsealed and unlabeled, three serving trays with food not covered, LPA felt a sticky kitchen floor, a dishwasher gauge showing a water temperature of 83 F degrees and LPA observed crumbs and beverage stains in three areas of the dining room floor. There were no kitchen staff present. BOM states staff were on break when LPA toured the kitchen.

On 7/29/21 at 3:00 pm, LPA interviewed the Business Office Manager who stated that kitchen staff typically clean the kitchen after the last resident is served which is sometime after the 1:30 pm for lunch and before staff break at 2:30 pm. She stated that staff sweep the dining room floor after each serving and mop at the end of the day.

Continued on 9099-C.

A credible Witness #1 (W1) visited the facility on 8/30/21 at 3:15 pm. W1 states they observed open trash and debris on the floor and walls in the kitchen and food left out in open containers. W1 provided photos which show a bag of onions on the floor in kitchen storage, four uncovered containers of chopped fruit, meat, and green beans on the kitchen counter, and the dishwasher gauge recording the water temperature just below 90 F degrees.

On 9/28/21 at 11:15 am, W1 observed six open containers with used cooking oil and fats sitting outside the backdoor to the kitchen on the ground, one oil-stained box, raw chicken sitting on a work table in an open plastic bag, and the back door open to the sidewalk.

On 2/18/22 at 12:01 pm, LPA visited the facility and observed that the kitchen dishwasher temperature registered at 100 F degrees.

Based on the evidence obtained, the allegation that, “Kitchen does not meet standards for food storage, cleanliness, and repair”, is deemed Substantiated. The facility did not follow procedures to ensure food safety, protection against contamination, and provide a clean, sanitized environment.