PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: A temperature check of the facility's water, accessible to persons in care, found the temperature to be 50.3° Celsius.
Corrective Action(s): Ensure that water accessible to persons in care, from any source, is not heated to more than 49° Celsius.
Date to be Corrected: January 19, 2022
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: An inspection of the physical facility found that a section of concrete (approximately 30 cm long) on the west side facility near the door is cracked, broken and lifting which requires repair.
Corrective Action(s): Ensure that all rooms and common area are maintained in a good state of repair.
Date to be Corrected: February 15, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: An inspection of the physical facility and grounds found a metal railing beside the backyard walking path to be separated (exposing sharp metal edges) which is unsafe. Additionally, behind the facility and in the side yard on the east side, gardening supplies were observed to left out (a wire cone typically used to support tomato plants was observed to be left in the side yard on the east side) which needs to be cleaned up and safely stored.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: January 26, 2022
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: A review of care plans for persons in care found that, for one person in care, there was no agreement in place to use a bed rail restraint given in writing by the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the persons in care (this is a repeat contravention).
Corrective Action(s): Ensure that there is agreement to the use of a restraint given in writing by the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Date to be Corrected: February 8, 2022
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: A review of three care plans found no written agreement from a medical practitioner or nurse practitioner responsible for the health of the persons in care to use a bed rail restraint for two persons in care (this is a repeat contravention).
Corrective Action(s): Ensure that written agreement is given by the medical practitioner or nurse practitioner responsible for the health of the person in care for the use of a restraint.
Date to be Corrected: February 8, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation (CORRECTED DURING INSPECTION): An inspection of the kitchen freezer found one item that was not labelled or dated (this is a repeat contravention).
Corrective Action(s): Ensure that all food is safely prepared, stored, served, and handled.
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: A review of the facility's menus found that they did not contain for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Corrective Action(s): Ensure that each menu provides for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Date to be Corrected: January 25, 2022
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: A review of three person in care records found that two out of three did not have consent in writing from the person in care or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Corrective Action(s): Ensure that written consent is obtain for each person in care from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Date to be Corrected: February 8, 2022
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: A review of the facility's menus found no evidence menu audits having been completed for the menus currently being used.
Corrective Action(s): Ensure that a record is kept of the results of monitoring of food services and nutritional care.
Date to be Corrected: January 25, 2022
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