PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: During the inspection of the physical facility, a gutter at the front of the facility was observed to be overflowing and/or leaking resulting in water splashing on the ground near the front entrance of the facility.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: November 29, 2021
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: Door alarms were observed to be in use on all bathroom doors to ensure the safety of persons in care; however, the use of these alarms was not recorded in the care plans of the persons in care.
Corrective Action(s): Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Date to be Corrected: November 4, 2021
RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: A review of the facility's menus found that a record of menu substitutions has not been kept since February 2020. When asked, facility management acknowledged that there have been menu substitutions since the last documented substitution that have not been recorded.
Corrective Action(s): Ensure that a record is kept of menu substitutions.
Date to be Corrected: October 25, 2021
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