Nutrition and Food Services:
* Emergency supplies are in-place, and there is a system in-place to rotate products as the writer viewed at the time of the inspection. The writer e-mailed a sample emergency menu to the Manager on May 11, 2021 to assist in developing one specific for Celebration & Rainbow Manor. Please let me know the outcome of this once it has been looked into.
* On-going education around nutrition is provided to staff. The writer e-mailed to the Manager on May 11, 2021 samples of education schedules for nutrition, and other considerations to take into consideration for on-going education (A total of 2 emails sent).
Physical Plant:
* When looking into the garage (right side) at the bottom there appears to be a small gap as light is coming in. The writer was advised that the rubber strip on the bottom of the garage door was changed last week and another measure will be looked at to address this to prevent any possible pest infestation. When looking at the garage door from front of the home, there doesn't appear to be a gap underneath the garage door. As the Licensee has been proactive in already addressing this and will look at other measures to further address this before the end of this week. Therefore this was not made a contravention.
* In the backyard side gate with the top portion of the gate slightly loose. The Licensee will ensure this is secured and doesn't move. The Licensee will address this before the end of this week. Therefore this was not made a contravention.
* In the back of the home, on the side of the house below the stairs that lead up to the 2nd floor, the Licensee has already self identified a crack in the pathway directly under the stairs. The crack doesn't affect the walking pathway or pose a fall risk given it's location at this time. The Licensee advised the writer there have been settling challenges with the house and in the past the Licensee has brought in a contractor to address this. The Licensee plans to address this in the summer of 2021. Therefore this was not made a contravention.
Medication:
* There is a process whereby care staff review the medication administration procedure and sign off as noted in the medication administration record binder. The writer recommended formalizing the "delegation of function" for medication administration for "non-professional" staff (Health Care Workers who are not Nurses) further by perhaps having the medication administration procedure as is already documented and adding the staff's contact information and date & signature at the bottom, and the contact details and date & signature of the staff providing the delegation (i.e., Nurse). A detailed discussion on what this could look like as is in-place at other sites was reviewed in detail.
Summary:
*Documentation overall appeared to be very thorough and the home (inside and outside) appears to be very well maintained.
Thank you to all the staff of Celebration & Rainbow Manor that took time to complete this routine inspection.
Due to the Covid-19 pandemic, the findings were reviewed and discussed with the Manager at the time of the inspection. This inspection report, and risk assessment was written off-site and then emailed on May 11, 2021 to the Manager for review and to finalize the report and risk assessment once they were in agreement to the wording. As a result of the pandemic, signature for the Manager is not included. If there are further questions related to this routine inspection, please contact your Licensing Officer. |