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 facility manager has been absent from the site for more than 30 days, with an interim manager in place. Licensing officer has sent change of manager forms to management twice in the month of February.
Corrective Action(s): Please submit the licensee declaration form for the change of manager within 30 days of the manager being absent
Date to be Corrected: March 11, 2022
LICENSING: 30160 - RCR s.11(1)(b) - A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility (b) the most recent routine inspection record made under section 9 (1)(d) of the Act.
Observation: The last routine inspection (2021) was not posted in the facility. The 2020 routine inspection was posted in the common area. This was discussed with management, it was requested that the 2021 routine inspection and risk rating be e-mailed to management.
Corrective Action(s): Ensure the most recent routine inspection is posted in a prominent place in the community care facility.
Date to be Corrected: March 11, 2022.
LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: The community care facility, does not have regular monitoring in place for the following systems: Care and supervision, and physical facility.
-monitoring of the physical facility, room temperature, as well as call bell response audits are being saved/ printed, however management was unable to describe how the call bell response times are being monitored. (Call bell response audits are a repeat contravention from the 2020 and 2021 routine inspections).
-The move in assessment, and valuables record was incomplete for one person in care who moved in 2021.
Corrective Action(s): Please provide a plan to licensing regarding a plan for monitoring the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Date to be Corrected: March 21, 2022
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: Inspection of the physical facility found:
-one bedroom had a broken baseboard heater, a metal piece was hanging down to the floor and not secured to the heater
-the shower room on the 2nd floor is being used for storage, and is not available to shower persons in care.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair. The bathing facilities that were approved when the building was licensed need to be maintained as such for the facility to maintain its transitional facility status.
Date to be Corrected: March 21, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31330 - RCR s.23(2)(a) - A licensee must ensure that no one other than a person in care engages in a restricted activity while on the premises of the community care facility,
Observation: Two staff were observed smoking on the community care facility property.
Corrective Action(s): Ensure staff are not smoking while on the premises of the community care facility.
Date to be Corrected: March 4, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31580 - RCR s.30(a) - A licensee must ensure that all bathrooms have (a) a door, equipped with a lock that can be opened from the outside in the case of an emergency.
Observation: The licensee has an approved exemption from 2017, to remove the bathroom door and replace with a curtain due to building structure and person in care mobility. It was observed on the second floor, that 4 bathroom doors have been removed, and have not been replaced with a curtain as required in the exemption details.
Corrective Action(s): It is the licensee's responsibility to ensure the submitted exemption plan is maintained.
Date to be Corrected: March 21, 2022
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: For one person in care who uses a restraint, there is no signed consent from the medical practitioner or nurse practitioner, or the family/guardian.
Corrective Action(s): Ensure there is written agreement for the use of restraints provided by the medical practitioner, and the family/ guardian of the person in care. As per RCR s. 74(1)(b)(i) and 74(1)(b)(ii)
Date to be Corrected: March 11, 2022
CARE AND/OR SUPERVISION: 34590 - RCR s.81(2)(b) - A care plan must be developed, to the extent reasonably practical, (b) in a manner that takes into account the unique abilities, physical, social and emotional needs, and cultural and spiritual preferences of the person in care.
Observation: One persons in care did not have a care plan addressing her unique physical abilities.
Corrective Action(s): Ensure a care plan is developed that takes into account the unique abilities, physical, social and emotional needs, and cultural and spiritual preferences of the person in care.
Date to be Corrected: March 21, 2022
CARE AND/OR SUPERVISION: 34680 - RCR s.81(3)(e)(ii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (ii) a plan for preventing the person in care from falling.
Observation: 2 out of 5 persons in care reviewed, did not have a fall care plan that addressed the nature of the risk of falling, or a plan to prevent falling for the persons in care.
Corrective Action(s): Ensure all persons in care have a fall prevention plan to assess the nature of the risk of falling, preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care.
Date to be Corrected: March 21, 2022
NUTRITION AND FOOD SERVICES: 37100 - RCR s.62(3) - The licensee must take all reasonable steps to ensure that the food served to persons in care follows the menu and, if unable to do so because of unforeseen circumstances, that the food provided to persons in care meets the nutritional requirements set out in subsection 62(2).
Observation: Discussion with the Food Service Manager confirmed, and along with review of the menu substitution list found that there are at least 10+ menu substitutions made based on staff preference/ convenience.
Corrective Action(s): Ensure all reasonable steps are taken to ensure that the food served to persons in care follows the menu, and substitutions are made form the same food group and have similar nutritional value to meet legislative requirements of RCR s.62(2)(d)
Date to be Corrected: Please submit an action plan by March 21, 2022.
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