Inspection Report
Census: 1
Capacity: 2
Deficiencies: 9
Jul 8, 2024
Visit Reason
The inspection was conducted to assess compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs for a Level I Residential Care Facility, including licensing, resident rights, medication procedures, health care, safety standards, and sanitation.
Findings
The facility was found to be out of compliance with multiple regulatory requirements including failure to post the license, failure to provide required information packets and resident rights documentation, unsafe medication procedures with expired medication orders and incomplete medication count records, lack of evidence of annual physical for a resident, absence of fire drill records, unsanitary food storage with expired items, and hot water temperature exceeding regulatory limits.
Severity Breakdown
Class II: 2
Class III: 3
Class IV: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to post the facility license where it can be seen and reviewed by the public. | — |
| Failure to provide required information packet to one resident including advance directives, licensing status, ombudsman brochure, and other required information. | — |
| Failure to provide Section 5 Resident Rights documentation to one resident. | Class IV |
| Failure to follow safe and acceptable medication procedures including expired medication orders for multiple medications. | Classes III |
| Medication count book missing required information and medication counts were not accurately recorded. | — |
| Failure to show evidence of an annual physical for one resident within the last year. | Class II |
| Failure to provide evidence of conducting required fire drills in the last year. | Class II |
| Failure to store food in the refrigerator in a sanitary manner, including presence of mold and expired milk. | Class III |
| Hot water temperature at kitchen sink exceeded 120°F, measured at 133.2°F. | Class III |
Report Facts
Census: 1
Total Capacity: 2
Medication counts missing: 4
Expired medication order date: Mar 21, 2024
Hot water temperature: 133.2
Expired milk date: Jul 1, 2024
Expired fruit date: Jun 11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexis Semuhoza | Administrator | Named as facility administrator |
| House Manager | Interviewed multiple times confirming findings and lack of documentation |
Loading inspection reports...
