Liberty Place Memory Care

Based on observation, staff interview and review of the facility policy, the facility failed to store all food in a manner that protected against contamination and storage. This had the potential to affect all of the residents residing in the facility. The facility census was 59 residents.

Findings include:

Observation on 03/06/25 at 8:58 A.M. with Dining Services Director (DSD) #40 revealed the following items were in the dry storage area: a canister of protein powder with an expiration date of 04/13/24, two boxes of tea bags with an expiration date of 2022, three cans of enchilada sauce with expiration dates of 10/02/24, an opened and unlabeled bag of pasta. Observation of the freezer revealed it contained an opened bag of French bread marked with a date of 02/14/25. Observation of the walk-in refrigerator revealed it contained the following items: a bag of onions on the floor, a half-gallon container of unlabeled and undated food, a container of unlabeled and undated food identified as frozen pulled pork per DSD #40.

Interview on 03/06/25 at 9:10 A.M. with DSD #40 confirmed the outdated protein powder, tea bags, and enchilada sauce in the dry storage area should have been removed and discarded. DSD #40 also confirmed the pasta should have been dated and sealed. DSD #40 confirmed no food should be stored on the floor of the refrigerator and any food thawing in the refrigerator should be marked with product identifiers and the date made.

Review of the facility policy titled Food storage Handling and Labeling dated 07/01/24 revealed all food in the walk-in refrigerator, the freezer and dry storage areas should be properly labeled and include produced-on and use-by dates. All dry, refrigerated and frozen foods should be stored in a clean and organized area six inches above the floor. Products should be marked with a date received and stored in the storeroom, walk-in refrigerator, and or freezer.

Based on observation, staff interviews, and review of the facility policy, the facility failed to provide and maintain a clean and sanitary kitchen. This had the potential to affect all residents residing in the facility. The facility census was 59 residents.

Findings include:

Observation on 03/06/25 at 0 8:55 A.M. with Dining Services Director (DSD) #40, revealed the inside of the ice machine had some greenish residue along the dispenser.

Interview on 03/06/25 at time of observation of ice machine with DSD #40 confirmed:

There the inside of the ice machine had some greenish residue along the dispenser and that it should not be there.

Observation on 03/06/25 at 11:55 A.M. with DSD #40 and Maintenance Manager (MM) #39 at the dishwasher where test strips were inserted to check sanitization level, revealed a solid blue color to the test strip. The dishwasher was run a second time and upon second sanitization check, the test strip was solid blue.

In an interview on 03/06/25 at the time of dishwasher observation, both the DSD #40 and the MM #39 confirmed the color of the strip is solid blue. They confirmed they were uncertain as to what color the test strips should be to show the dishwasher is sanitizing at the proper level for the safety of the residents. They further confirmed they may have the wrong strips for testing as the machine is new to the facility.

Review of the facility policy titled Sanitation Overview, dated 07/01/2024, under Kitchen Sanitation line five for cleaning schedule it reads, Ice Machine: interior of the ice machine will be kept clean and free from slime and or mold at all times.

There were no instructions or guidelines with regard to the dishwasher and acceptable sanitizing levels made available for review. This was confirmed in an interview with MM#39 at 4:00 P.M.

Based on record review and staff interview, the facility failed to conduct fire drills once per shift at least every three months. This has the potential to affect all of the residents residing in the facility. The facility census was 59 residents.

Findings include:

Review of the fire drill records provided by the Executive Director dated 03/27/24 to 02/09/25 revealed the facility held third shift fire drills on 05/16/24 at 4:00 A.M.; 09/06/24 at 6:30 A.M. and 12:10/24 at 6:27 A.M. Review of the fire drills revealed the facility did not have a third shift fire drill during June, July, and August of 2024.

Interview on 03/06/25 at 4:30 P.M. with the Executive Director confirmed the facility had not completed a third shift fire drill during the months of June, July, and August of 2024.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure laundry dryer lint traps were free from lint. This had the potential to affect all of the residents residing in the facility. The facility census was 59 residents.

Findings include:

Observation on 03/06/25 at 12:17 P.M with Housekeeper #31 in the facility laundry area revealed there was a buildup of lint in both of the dryers.

Interview on 03/06/25 at 12:18 P.M. with Housekeeper #31 confirmed there was a buildup of lint in both of the dryers.

Interview on 03/06/25 at 12:20 P.M. with Maintenance Manager (MM) #39 confirmed the dryers should be cleared of lint at least three times a day.

Review of the facility policy titled Laundry Dryer Fire Prevention undated revealed the facility would maintain a safe environment for residents, families and staff, free of fire and smoke hazards and would ensure the dryer lint traps were cleaned three times daily at 7:00 A.M., 12:00 P.M. and 2:00 P.M.

Based on record record review and staff interview, the facility failed to obtain criminal background checks on employees. This had the potential to affect all 56 residents residing in the facility.

Findings include:

Review of the personnel file for Employee #20 revealed her first day worked at the facility was 5/16/22. There was no information regarding a criminal background check.

Review of the personnel file for Employee #30 revealed her first day worked at the facility was 04/11/23. There was no information regarding a criminal background check.

Review of the personnel file for Employee #34 revealed her first day worked at the facility was 07/18/22. There was no information regarding a criminal background check.

Review of the personnel file for Employee #40 revealed her first day worked at the facility was 03/23/23. There was no information regarding a criminal background check.

Review of the personnel file for Employee #46 revealed her first day worked at the facility was 05/16/22. There was no information regarding a criminal background check.

Review of the personnel file for employee #49 revealed her first day worked at the facility was 01/05/16. There was no information regarding a criminal background check.

Review of the personnel file for Employee #52 revealed her first day worked at the facility was 01/17/23. There was no information regarding a criminal background check.

Interview on 01/24/24 at 3:30 PM with Administrator verified the facility failed to complete a criminal background check on the staff members Employees #20, #30, #34, #40, #46, #49, and #52.

Based on record review and staff interview, the facility failed to conduct fire drills on each shift at least every three months. This has the potential to affect all 56 residents residing in the facility. Facility census was 56.

Findings include:

Review of the fire drill reports provided by the Executive Director dated 01/27/23 to 12/29/23 revealed for the second quarter (April, May, and June), there were no fire drills completed for Second and third shifts. For the third quarter (July, August, and September) there were no fire drills completed for first and second shifts.

Interview on 1/24/24 at 3:30 P.M. with the Executive Director confirmed the facility did not complete fire drills on a quarterly basis for each shift.