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: In review of the Dietitian binder the following was noted:
* Choking risk Management document noted with a year of 2021 noted and this will be reviewed with the Dietitian on January 18, 2024 to ensure the list of persons in care noted is current and ensure a current date is noted for this document.
Corrective Action(s): Please ensure the care and services provided by the facility are regularly monitored to ensure that the requirements of the Community Care & Assisted Living Act and Residential Care Regulation are being met.
Date to be Corrected: January 18, 2024.
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: In the backyard/courtyard where there are tables and at the end of the facility there were two vehicles parked. Behind one vehicle was a orange coloured cone noted. Upon further review it appears a portion of the asphalt material on the pavement is not present and this possibly presenting as a potential tripping hazard.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: January 31, 2024.
STAFFING: 32020 - RCR s.37(1)(b) - 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: (b) character references in respect of the person.
Observation: In review of staff files, it was noted for a staff member did not have any character references on file.
Corrective Action(s): Please ensure staff have character references on file as required.
Date to be Corrected: January 31, 2024.
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: In review of staff files, it was noted for a staff member did not have tuberculosis clearance or immunizations on file.
Corrective Action(s): Please ensure staff have their tuberculosis clearance and immunizations on file as required.
Date to be Corrected: January 31, 2024.
STAFFING: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: In review of staff files, it was noted for a staff member their performance appraisal has not been completed since 2018.
Corrective Action(s): Please ensure performance appraisals are reviewed both regularly and continues to meet the requirements of the residential care regulation.
Date to be Corrected: January 31, 2024.
POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation: There is no emergency menu in-place. The Licensing Officer e-mailed a sample emergency menu to guide the site in developing their own.
Corrective Action(s): PLease ensure there is an emergency menu in-place.
Date to be Corrected: January 31, 2024.
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: For example the spring/summer menus as documented have fruit noted as the first snack offered which is only 1 food group.
Corrective Action(s): Please ensure that each menu provides for each day at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Date to be Corrected: January 31, 2024.
RECORDS AND REPORTING: 39480 - RCR s.87(d) - A licensee must keep a record of the following matters respecting food services: (d) food services and nutrition care education and training programs attended by food services employees.
Observation: In discussion with the Manager of Care assisted feeding techniques are discussed for example during shift report, however there is no records as to the staff that participated.
Corrective Action(s): Please ensure a record of the food services and nutrition care education and training programs attended by food services employees is kept on file.
Date to be Corrected: January 16, 2024.
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