LICENSING: 30030 - RCR s.8(2)(a)(ii) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (ii) a description of how the licensee intends to ensure the health and safety of persons in care while the change is being made.
Observation: The facility manager reported the lower washroom shower was renovated. The washroom is used by a person in care with mobility challenges and the PIC temporarily did not have access to this washroom. CCFL did not received a health and safety plan..
Corrective Action(s): In future, please ensure to submit a health and safety plan to CCFL for structural changes.
Date to be Corrected: October 27, 2021
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: One length of backyard fence was missing three sections of boards. Two section were 3 to 4 feet across and one section as 1 to 2 feet across. A piece of kitchen cabinetry was missing above the oven.
Corrective Action(s): Please ensure the backyard fence and kitchen cabinetry are maintained in a good state of repair.
Date to be Corrected: December 31, 2021
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: Numerous items were being stored in the lower living room including a bed frame, broken speakers, plastic totes, an empty dresser, sleeping bags, and suitcases. The facility manager reported these items were not currently needed. The previous routine inspection report noted items were stored in this area and at that time the manager stated the items would be removed.
Corrective Action(s): Please ensure clean condition of common areas.
Date to be Corrected: November 30, 2021
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: 1 person in care has a separate list of suggested snacks. Licensing observed 8/14 snacks contained only 1 food group.
Corrective Action(s): Please ensure each snack contains two food groups.
Date to be Corrected: November 30, 2021
NUTRITION AND FOOD SERVICES: 37070 - RCR s.62(2)(c)(iii) - A licensee must ensure that each menu provides (c) a variety of foods, taking into consideration (iii) seasonal variations in food.
Observation: The facility manager reported the same menu to remain in place year round. The most recent menu update was documented as July 2020.
Corrective Action(s): Please ensure seasonal variation to the menu.
Date to be Corrected: December 31, 2021
RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: There was not a record of 1 person in care’s TB status. [Repeat contravention documented in Routine Inspection NBIH-BLGTY3, February 3, 2020]
Corrective Action(s): Please ensure there is a record kept of each person in care’s TB status.
Date to be Corrected: November 15, 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: As per the facility manager, persons in care select snacks from a bin of preferred items rather than what is listed on the menu. These substitutions were not observed to be recorded on the menu substitution list.
Corrective Action(s): Please ensure a record is kept of substitutions to the menu.
Date to be Corrected: November 15, 2021
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