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: Licensing observed the following concerns in common areas:
- Washroom #1: cracked tile of 1’ x 1’, rust on electrical outlet cover, mold surrounding bathtub, mildew in tub/shower
- Washroom #2: one tile missing, 2” paint stain on the floor
- 6’ wide section of fence missing
- Two fence boards falling down
- 6 lower kitchen cupboard doors blackened due to possible rot and the coating over the wood has worn off
- Wood lining the base of the lower kitchen cupboards was blackened due to possible rot
Corrective Action(s): Ensure rooms and common are maintained in good stated of repair.
Date to be Corrected: April 30, 2022
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: Licensing observed the following concerns in common areas:
- Debris from a deck and stair removal consisting of 8 concrete blocks and 8 bricks, brick fragments of 2-4”, wood splinters up to 12”, exposed splintered wood on the side of the house in an area of approximately 1’ x 3’.
- 3 wooden boards with 1-2 nails protruding from each left near the side door
- Fire extinguishers were stored in the garage (corrected by day 2 of inspection)
-Thorny bushes within the fence line
- Washroom #2: mold present in all areas where wall tiles met the flooring
Corrective Action(s): Ensure rooms and common areas are maintained in safe and clean condition.
Date to be Corrected: March 31, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Licensing observed cleaning agents accessible to PICs on counters in the kitchen, bathroom, and laundry room. Cupboards for storing cleaning agents were unlocked in three areas of the home. One cupboard did not have a built-in lock or strategy for locking.
Corrective Action(s): Ensure secure storage for cleaning agents.
Date to be Corrected: February 11, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: Slip resistant flooring was not present in the laundry area used by PICs.
Corrective Action(s): Ensure slip resistant flooring in the laundry area.
Date to be Corrected: March 11, 2022
STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Performance reviews had not been completed for 6 out 6 employees within the past year. The facility policy is to complete performance reviews each year.
Corrective Action(s): Ensure regular reviews of employee performance.
Date to be Corrected: March 25, 2022
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: For the past three months, one staff has been working alone without valid first aid and CPR.
Corrective Action(s): Ensure employees with valid first aid and CPR certificate are immediately accessible.
Date to be Corrected: March 4, 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: Site specific policies had not been reviewed since 2018.
Corrective Action(s): Ensure policies and procedures are reviewed once per year.
Date to be Corrected: March 25, 2022
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Care Plans had not been reviewed for more than two years.
Corrective Action(s): Ensure care plans are reviewed at lease once each year.
Date to be Corrected: March 4, 2022
MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored.
Observation: It could not be determined when a pharmacist last inspected the medication storage area. Record of inspection could not be provided and expired medications dating back to 2020 were observed in a bin marked for return to pharmacy.
Corrective Action(s): Ensure the supervising pharmacist inspects the medication storage area.
Date to be Corrected: March 31, 2022
MEDICATION: 36060 - RCR s.68(2)(c) - A licensee must appoint a supervising pharmacist to (c) consult with employees respecting medication interactions and other problems related to medication.
Observation: It could not be determined when the pharmacist provided consultation regarding drug interactions or problems, as evidence of Medication Safety and Advisory Committee (MSAC) meetings could not be provided.
Corrective Action(s): Ensure the supervising pharmacist consults with employees regarding medication interactions and problems
Date to be Corrected: March 31, 2022
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: One PIC’s record did not include a consent to call a medical/nurse practitioner or ambulance in the event of an accident or injury (This is a repeat contravention from Routine Inspection AKUR-BM5SNN).
Corrective Action(s): Ensure PIC’s records include written consent to call a medical/nurse practitioner.
Date to be Corrected: March 31, 2022
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: Record of menu substitutions were missing for meals and snacks over a 24 hour period and for daily breakfast substitutions happening for a minimum of one month.
Corrective Action(s): Ensure a record is kept of substitutions to menus.
Date to be Corrected: February 11, 2022
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: An audit evaluating the nutritional value of the fall/winter menu could not be located.
Corrective Action(s): Ensure records are kept of the result of monitoring food service and nutrition care.
Date to be Corrected: March 11, 2022
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