Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.

Corrective Actions Required: Ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: November 27, 2024

Observations: Licensing tested the hot water at five water sources accessible to persons in care. The water temperature at one sink was 58° Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. The Director of Care spoke with maintenance on this date to have the hot water temperature adjusted. Full compliance will not be achieved until the plan has been implemented and completed.

Description: A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is a nutrition manager with membership in the Canadian Society of Nutrition Management,

Corrective Actions Required: Ensure that there is a Food Services Manager who is a nutrition manager with membership in the Canadian Society of Nutrition Management (CSNM).

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: December 27, 2024

Observations: The Director of Care and Manager stated that there was not a Food Services Manager to supervise the preparation and delivery of food who had a membership in the Canadian Society of Nutrition Management (CSNM).

Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,

Corrective Actions Required: Ensure that each person in care is weighted at least once each month.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: December 27, 2024

Observations: Licensing reviewed weight records for seven persons in care. Records for two persons in care were missing more than one weight in the past 12 months.

Description: A licensee must keep the following records in respect of each employee: a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.

Corrective Actions Required: Ensure that there are records for performance reviews for each employee.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: February 27, 2025

Observations: Licensing reviewed ten staff records.. The Director of Care stated that performance reviews are conducted verbally and that not all had a record of the performance review conducted. The Director of Care stated that approximately ten percent of staff had a performance review record on this date.