Inspection Report
Biennial Survey
Census: 1
Capacity: 2
Deficiencies: 5
Jun 27, 2024
Visit Reason
The inspection was a biennial survey to assess compliance with regulations governing Level I Residential Care Facilities and Infection Prevention and Control.
Findings
The facility was found non-compliant with multiple regulatory requirements including failure to have a signed standard contract by the resident, failure to append a copy of the admission policy to the contract, incomplete resident summary sheets missing emergency contact and medical/social information, failure to maintain a list of resident personal property, and failure to maintain proof of rabies vaccination for a household cat, which was a repeat deficiency.
Severity Breakdown
Class III: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Resident record failed to have a signed standard contract by the resident. | — |
| Provider failed to append a copy of the admission policy to the standard contract. | — |
| Resident summary sheet did not contain nearest relative or friend’s name, address and telephone number, person to be notified in an emergency, and significant medical/social issues. | — |
| Provider failed to maintain a list of resident property including items of personal value. | — |
| Facility failed to maintain proof of rabies vaccination for a household cat; repeat deficiency. | Class III |
Report Facts
Census: 1
Total Capacity: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leopold Ndayisabye | Administrator | Named as facility administrator |
| Chief Executive Officer (CEO) | Interviewed to confirm findings |
Inspection Report
Complaint Investigation
Census: 1
Capacity: 3
Deficiencies: 0
Mar 6, 2023
Visit Reason
The visit was conducted as a complaint investigation for the facility 1 Pond Road, a Level I Residential Care Facility.
Findings
The facility was found to be in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level I Residential Care Facilities, Part of 10-144, Chapter 113.
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