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: Noted during inspection of common areas and rooms:
In the 4 care areas the walls, doors and trim in the hallways are missing paint with deep scrapes and chips of varying sizes and a number of black marks and scuffs.
In 12 rooms, it is noted that 3 of 12 rooms have missing paint on the lower half of the wall with deep scrapes in that vary from 10cm -50cm in length.
Corrective Action(s): Please ensure that all rooms and common areas are (b) maintained in a good state of repair.
Date to be Corrected: Feb 27, 2023
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: Noted during inspection of a tubroom (Maple) has 2 large sections of missing flooring(each approximately 60-75 cm long by 20-30 cm wide), it appears that water continues to seep under these sections of flooring near the drain.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: February 27, 2023
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: Noted during inspection two utility room doors were propped open with a wooden wedge.
Corrective Action(s): Please ensure secure and safe storage areas for cleaning agents, chemical products and other hazardous materials.
Date to be Corrected: Feb 27, 2023
STAFFING: 32040 - RCR s.37(1)(d) - 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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: A spreadsheet provided by the manager shows that 12 (of 110) employees have an expired Food Safe certificate, which is a requirement of their position.
Corrective Action(s): Please ensure to obtain copies af diplomas, certificates or other evidence of the person's training and skills
Date to be Corrected: Feb 27, 2023
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: During discussion with management it was confirmed that less than 10% of performance reviews have been completed for employees. The team has created a schedule and continues to make this a focus.
Corrective Action(s): Please ensure that performance of each employee is reviewed regularly and as directed by the MHO.
Date to be Corrected: Feb 27, 2023
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: Management provided a spread sheet that shows 5 of 12 employees have expired first aid and CPR Certificates.
Corrective Action(s): Please ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate.
Date to be Corrected: Feb 27, 2023
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: During inspection- monitoring of the call bell system noted that 3 of 12 calls took more than 7 minutes for staff to respond to the persons in care, this is longer than the facilities' accepted policies/practice.
Corrective Action(s): Please ensure that staff implement policies and procedures.
Date to be Corrected: Feb 27, 2023.
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: Noted during review of 12 persons in care (PICs) charts, 1 PIC who is at risk for aggressive behaviour is overdue for a scheduled behaviour risk assessment.
Corrective Action(s): Please ensure that the care and supervision of a PIC is consistent with the terms and condition of their care plan.
Date to be Corrected: Feb 27, 2023
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