PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31070 - RCR s.16(2)(a) - A licensee must ensure that each bedroom, bathroom and common room is lit sufficiently to (a) permit a person to carry out effectively the types of activities that would be reasonably expected in the ordinary use of the room.
Observation: Inspection of the master bedroom's en suite bathroom found that the light by the shower and one of the lights by the mirror and sink was burnt out. This is a repeat contravention from last years routine inspection (NTJN-A57QAW).
Corrective Action(s): Ensure that each room has sufficient lighting to permit a person to carry out the types of activities that would reasonably be expected in each room.
Date to be Corrected: October 26, 2016
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: The fire extinguisher located upstairs in the pantry expired in October of 2015. The manager stated that there is another fire extinguisher in the upstairs kitchen, which expires in about 10 days. The manager stated that she would make an appointment to have the equipment inspected.
Corrective Action(s): Please ensure that all emergency equipment is inspected on a regular basis.
Date to be Corrected: October 26, 2016
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31590 - RCR s.30(b) - A licensee must ensure that all bathrooms have (b) slip resistant material on the bottom of each bathtub and shower.
Observation: One of the showers on the second floor did not have slip resistant material on the shower floor.
Corrective Action(s): Please ensure that each bathtub and shower has slip resistant material.
Date to be Corrected: October 26, 2016
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: A review of all 5 Person in Cares (PIC) medication administration records (MAR) showed that 1 PIC's MAR had not been initialed the day before for 4 medications which were administered at 8 pm. Discussion with the manager stated that the policy is to initial the MAR for all administered medications. Review of the sheet which staff are to sign at the end of their shift indicating that they have checked the MARs showed that the staff had signed it, although the signatures were not present on the MAR.
Corrective Action(s): Please ensure that staff comply with the policies and procedures outlined by the medication safety and advisory committee.
Date to be Corrected: October 5, 2016
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: A review of the downstairs and upstairs fridges and freezers found that 3 bags of bananas, 2 Popsicles, and a package of fish had been either removed from their original box or placed in a sealable bag which was not labelled.
Corrective Action(s): Please ensure that all food is safely prepared, stored, served, and handled.
Date to be Corrected: October 5, 2016
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: A review of the substitution record found the following:
- Hard boiled eggs and peanut butter toast was substituted for cinnamon French toast. Although the cinnamon French toast does contain eggs it does not have the same nutritional value as hard boiled eggs. There had also been other substitutions which did not have the same nutritional value. This is a repeat contravention from last year's routine inspection (NTJN-A57QAW)
- The substitution record also did not have any substitutions recorded after June of 2016 even though the manager stated that substitutions had still been occurring.
Corrective Action(s): Please ensure that a substitution record is kept and that substitutions made are from the same food group and have a similar nutritional value.
Date to be Corrected: October 5, 2016
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: Licensing was unable to determine if the PICs are receiving adequate food to meet their personal nutritional needs as there were no audits for the menus.
Corrective Action(s): Please ensure that each PIC receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and each PICs' nutrition care plan.
Date to be Corrected: October 26, 2106
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of 5 PICs' monthly weight charts found the following:
- 1 PIC was not weighed in March and April of 2016
- 1 PIC was not weighed in August of 2016
Both weight charts did not indicate why they had not been weighed. This is a repeat contravention from last year's routine inspection (NTJN-A57QAW).
Corrective Action(s): Please ensure that each PIC is weighed at least once each month.
Date to be Corrected: October 5, 2016
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