Lochhaven

Based on observation, staff interview, and review of policy, the facility failed to ensure personal protective equipment (PPE) was available for staff for sorting and handling soiled laundry. This had the potential to affect the 60 residents who resided in the facility. The facility census was 60.

Findings include:

Observation on 03/31/26 at 7:55 A.M. of the third floor laundry room found gloves available outside of the laundry room for handling soiled laundry. No gowns were found.

Observation on 03/31/26 at 8:00 A.M. of the second floor laundry room found disposable gloves were found outside of the laundry room for handling soiled laundry but no gowns were found.

Observation on 03/31/26 at 10:00 A.M. of the second floor laundry room found there continued to be no gowns available.

Interview on 03/31/26 at 3:09 P.M. with RA #231 verified gowns and gloves were required to be used when handling soiled laundry. Coinciding observation of the third floor verified there were no gowns available for use to handling soiled linens.

Interview on 03/31/26 at 3:11 P.M. with RA #231 verified there were gloves but no gowns available in the second floor laundry.

Interview on 03/31/26 RA #235 also verified when staff were handling soiled resident laundry the required PPE was a gown and gloves.

Review of the facility policy titled, Laundry-Assisted Living

Based on record review and staff interview, the facility failed to include residents in the fire evacuation drill process as required. This had the potential to affect 60 of 60 residents residing in the facility. The facility census was 60.

Findings include:

Review of documents titled, LH Fire Drill W/Evacuation

Based on observation, staff interview, and review of facility policy, the facility failed to ensure hazardous materials were kept secured. This had the potential to affect two residents (#23 and #20) who the facility identified as cognitively impaired and independently mobile. The facility census was 60.

Findings Include:

Observation on 03/31/26 at 7:55 A.M. of the third floor laundry room found an opened one gallon bottle of bleach and 24 fluid ounce bleach toilet cleaner spray bottle open, unsecured and on the shelf next to the washing machine within reach of residents. The bottle of bleach and bottle of bleach spray cleaner were labeled keep out of reach of children.

Interview on 03/31/26 at 7:57 A.M. with Resident Assistant (RA) #237 verified the chemicals in the laundry room were not secured and within reach of residents.

Observation on 03/31/26 at 8:00 A.M. of the second floor laundry room found a gallon bottle of bleach open, unsecured and on the shelf next to the washing machine within reach of residents. The bottle of bleach was labeled keep out of reach of children.

Observation on 03/31/26 at 10:00 A.M. of the second floor laundry room found the opened gallon bottle of bleach continued to be on the shelf unsecured next to the washing machine.

Interview on 03/31/26 at 10:23 A.M. with RA #233 verified there was a bottle of open bleach unsecured on the shelf of the laundry room.

Review of the undated facility policy titled, Safe Storage Poisons and Hazardous Materials Policy

Based on observations and staff interview, the facility failed to ensure the kitchen procured, stored, prepared and served food to protected against contamination and spoilage as required. This had the potential to affect all 59 residents residing in the facility who received their food from the kitchen. The facility census was 59.

Findings included:

On 02/26/25 at 9:00 A.M. observation of the facility kitchen revealed Cook #1 and Dietary Aide #2 were in the kitchen and food preparation area without hair nets. Further observations of the facility kitchen revealed dirty fruit cups and small plates on the floor under the dishwasher. Upon entrance into the walk-in refrigerator an open glass of milk without a cover was on the shelf without a date and there were no dates on an opened pie and ham lunch meat. The walk-in freezer had one opened bag of chicken breast, one opened bag of french fries and one opened bag of hamburger patties with no dates indicating when the items had been opened. There were scattered french fries on floor of the walk-in freezer.

On 02/26/25 at 9:10 A.M. interview with Cook #1 verified staff should wear hair nets while in the kitchen and food preparation area. Cook #1 verified the dirty dishes on the floor under the dishwasher and the scattered food on the floor in the walk-in freezer. Cook #1 verified food items should be covered and/or closed when in the refrigerator/freezer and food items should be dated when opened. The facility confirmed all 59 residents receive food from the facility kitchen.

Based on review of facility documents, staff interview and policy review, the facility failed to perform disaster preparedness drills as required. This had the potential to affect all 61 residents residing in the facility. Facility census was 61.

Findings include:

Review of the facility disaster drill log dated 07/01/22 to 06/29/23 revealed there were no evidence of disaster drills for the time period.

Interview on 06/29/23 at 1:13 P.M. with the Supervisor Environmental Services #49 confirmed the facility had not performed any disaster drills for the year 2022 and had not performed any disaster drills for 2023.

Review of a facility policy titled Fire - Disaster - Evacuation Policy, not dated revealed tornado and disaster drills will be conducted two times a year. Drills are conducted to outline steps for residents and staff to take during a drill or real emergency.