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: An inspection of the physical facility found the following:
1) At the entrance to the facility, a gutter (which staff report had been hit by a mail truck approximately 3 weeks before) was crushed and leaking.
2) Metal trim on the floor (at the entrance to one shower for use by persons in care) was detached and sticking up approximately 3 cm (corrected during inspection).
3) In another shower for use by persons in care, a floor tile was missing and a broken piece of tile was on the floor.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: May 18, 2021
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: An inspection the facility's bathrooms for use by persons in care found that there was a battery charger in two bathrooms plugged in approximately 15 cm from a water source and in one bathroom there was a wardrobe that was unstable when the doors were opened (corrected during inspection).
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe condition.
Date to be Corrected: May 12, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31590 - RCR s.30(b) - A licensee must ensure that all bathrooms have (b) slip resistant material on the bottom of each bathtub and shower.
Observation: An inspection of the facility's bathrooms found that two showers did not have slip resistant material on the floor.
Corrective Action(s): Ensure that all bathrooms have slip resistant material on the bottom of each bathtub and shower.
Date to be Corrected: May 18, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31850 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation: A review of the facility's menus found that the menu posted was for the wrong week and did not match the menu that was being served.
Corrective Action(s): Ensure that the proper week's menu is displayed in a prominent place in each dining area for each weekly period (corrected during inspection).
Date to be Corrected: May 11, 2021
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: A review of the facility's emergency supplies found that there was insufficient food and water to sustain persons in care and staff for 3 days.
Corrective Action(s): Ensure that emergency supplies are adequate to support persons in care and staff for 3 days.
Date to be Corrected: May 24, 2021
POLICIES AND PROCEDURES: 33220 - RCR s.85(1)(a) - A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Observation: A review of care plans found that one care plan had a pin belt in place; however, there was no evidence of a written policy or procedure to guide staff on the proper use of the pin belt.
Corrective Action(s): Ensure that written policies and procedures are in place for the purpose of guiding staff in all matters relating to the care and supervision of persons in care.
Date to be Corrected: May 24, 2021
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: A review of care plans found that one person in care had a fall prevention plan that called for a chair alarm to be in place; however, this person in care was observed to be in a chair without a chair alarm in place (corrected during inspection).
Corrective Action(s): Ensure that the care and supervision of a person in care is consistent with the term and conditions of the person in care's care plan.
Date to be Corrected: May 11, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: A review of staff files found that 4 staff members had immunization records that were incomplete.
Corrective Action(s): Ensure that persons employed in a community care facility provide evidence of continued compliance with the Province's immunization and tuberculosis programs.
Date to be Corrected: May 25, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: An review of person in care admission records found that two persons in care had incomplete immunization records and one person in care had no record of immunization status or tuberculosis screening.
Corrective Action(s): Ensure that all persons admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: May 25, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: An inspection of the facility's kitchen found that one item in the fridge was past its best before date. Additionally, it was observed that one item in the fridge and two items in the freezer that were not dated (corrected during inspection).
Corrective Action(s): Ensure that all food is safely stored.
Date to be Corrected: May 11, 2021
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: A review of the facility's menu substitutions record found that the last menu substitution recorded was on October 29, 2020; however, staff reported that a menu substitution had occurred on the day of the inspection which was not recorded. Staff also report that other substitutions would have occurred during the holiday season that were not recorded.
Corrective Action(s): Ensure that a record is kept of all menu substitutions.
Date to be Corrected: May 11, 2021
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