LICENSING: 30060 - RCR s 8(3)(b) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (b) replace the manager, either by hiring a person who, or using a hiring process that, is approved in writing by the medical health officer.
Observation: The current manager's start date was July 28, 2020. The geographical Licensing Officer (LO) received an application to amend the license forms on August 7, 2020. On August 10th, 2020 the LO informed the Licensee that the form was missing information and required the signature of the Licensee. Despite 3 subsequent instructional emails to the Licensee, the LO has yet to receive, and approve, appropriately completed forms.
Corrective Action(s): Ensure that a manager of a community care facility is hiring using a process that is approved in writing by a medical health officer
Date to be Corrected: April 30, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: Upon inspection of the facility there were found to be items that were in need of repair and they include the following;
-the laminate coating on a PIC's dresser has cracked off in several areas
-the arm of the sofa is torn
-the shelving surface in the linen area is damaged
Of concern is the damage to these items creates a challenge when trying to clean them.
Corrective Action(s): Ensure that all furniture and equipment used by PICs are maintained in a good state of repair.
Date to be Corrected: April 30, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: Upon inspection of the facility there were observed to be furniture and or equipment that were not maintained in a safe and/or clean condition, these include;
-the dryer vent did not appeared to have been serviced as there were large amounts of lint accumulating outside the vent, of concern is the potential risk for fire
-the small fridge located downstairs was very odorous, in conversation with facility staff it was determined that his fridge is used by the PICs. It did not appear to have been cleaned recently.
-the toilet seat in room 8 was very worn, of concern is that it cannot be disinfected as required
Corrective Action(s): Ensure that all furniture and equipment used by PICs is maintained in a safe and clean condition.
Date to be Corrected: April 30, 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: Upon inspection of this facility, there was found to be several areas where repairs are required, these include the following;
-kitchen ceiling drywall shows evidence of a water leak
-kitchen ceiling light fixture shows evidence of water leaking into it,
-ceiling drywall in the main staircase area is damaged
-caulking in the bathtub area is not intact in some areas and is black
-the door between the office and the kitchen and the door to room 4 sticks, making it difficult to open
-the window on the staircase landing has a broken screen.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: April 30, 2021
STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: Review of 4 employee files found that files 2 were missing a criminal record check.
Corrective Action(s): Ensure that the licensee does not employ a person in a community care facility unless they have obtained a criminal record check for that person.
Date to be Corrected: April 30, 2021
STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Review of 4 employee files has found that 2 did not contain evidence of compliance with the Province's immunization and tuberculosis control programs.
Corrective Action(s): Ensure that the facility manager does not employ a person in a community care facility unless they obtain evidence of compliance with the Province's immunization and tuberculosis control programs.
Date to be Corrected: April 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: Review of the facility menus found that the snacks offered did not always contain 2 food groups as described in Canada's Food Guide.
Corrective Action(s): Ensure that snacks are nutritious and contain 2 food groups.
Date to be Corrected: April 30, 2021
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: An incident occurred on June 21, 2020 whereby a person in care (PIC) required hospitalization and the facility did not submit a reportable incident form to a medical health officer. This incident was brought to the attention of the geographical Licensing Officer who informed facility staff that an incident report was required. A incident report was submitted on October 5th, 2020, 4 months after the date of the incident. This is a repeat contravention.
Corrective Action(s): Ensure that if a PIC is involved in a reportable incident, that a medical health officer is notified immediately in the required manner.
Date to be Corrected: April 30, 2021
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: Review of the facility menu found there was no accompanying audit. Of concern is the nutritional elements have not been audited to ensure that the menu meets the nutritional requirements of the PICs. This is a repeat contravention.
Corrective Action(s): Ensure that records are kept related to monitoring of food services and nutrition care.
Date to be Corrected: April 21, 2021
|