Deficiencies per Year
8
6
4
2
0
Severe
Moderate
Unclassified
Inspection Report
Biennial Survey
Census: 21
Capacity: 24
Deficiencies: 6
Dec 31, 2024
Visit Reason
The visit was a biennial survey to assess compliance with regulations governing the licensing and functioning of Level IV Residential Care Facilities, including infection prevention and control standards.
Findings
The facility was found non-compliant with infection prevention and control requirements, food storage and sanitation standards, physical plant maintenance, and water temperature regulations. Multiple deficiencies were observed including lack of a written Infection Prevention and Control Plan, food stored under unprotected water lines, uncleanable shelving surfaces, outdated food items in use, maintenance issues with call bells and stairs, residue buildup in ice machine, and hot water temperature exceeding 120°F.
Severity Breakdown
Class III: 2
Class I/II: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to develop a written Infection Prevention and Control Plan (IPCP) including required elements. | — |
| Food or containers stored under unprotected sewer or water lines. | Class III |
| Shelving in storage areas had uncleanable surfaces due to unfinished wood. | — |
| Use of outdated food items such as leftover containers past use-by dates. | Class I/II |
| Lack of routine maintenance evidenced by non-functioning call bells, spongy boards and wobbly handrails on stairs, and residue buildup in ice machine. | — |
| Hot water temperature in resident areas exceeded 120°F, measuring 123°F. | Class III |
Report Facts
Census: 21
Total Capacity: 24
Hot water temperature: 123
Date of IPCP review request: Surveyor requested IPCP on 12/3/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nichole Lessard | Administrator | Named in relation to IPCP deficiency and exit meeting |
| Director of Operations | Named in relation to IPCP deficiency and confirmation of findings |
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