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: In many rooms and common areas through out the house there were burnt out light bulbs
Corrective Action(s): Please ensure that there is sufficient lighting in all areas of the facility
Date to be Corrected: February 16, 2022
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Review of the policy and procedure manual noted that the last review of the manual was in 2020
Corrective Action(s): Please ensure the policy manual is review and if necessary updated yearly
Date to be Corrected: March 2, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: 1 of 3 care plans reviewed was missing TB documentation
Corrective Action(s): Please ensure all PIC's have a record of their TB status on file
Date to be Corrected: March 2, 2022
NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Review of the four week menu noted that there were only 2 food groups in the morning meals and little variation
Corrective Action(s): Please ensure that the menu contains the proper number of food groups for each meal and sufficient variety
Date to be Corrected: March 2, 2022
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