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: Some wall and corner space had areas of exposed drywall.
Corrective Action(s): Please ensure the common space is in good state of repair.
Date to be Corrected: March 18, 2022
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: 4 staff files information was reviewed, one staff was missing evidence of compliance of the TB program.
Corrective Action(s): Please ensure staff file is complete and compliance has been met.
Date to be Corrected: February 16, 2022
STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Yearly performance evaluation for the 3 staff was required on October 2021. Leadership is aware of when the evaluation was required for the 3 staff.
Corrective Action(s): Please ensure performance of each employee is reviewed on a regular basis. The facility Policy is that the performance review is conducted on a yearly basis.
Date to be Corrected: March 1, 2022
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: There were 3 times when a staff person without a valid first aid worked alone, therefore immediate access to an employee with a valid first aid was not in place.
Corrective Action(s): Please ensure that at all times, there is an immediate access to an employee with a valid first aid.
Date to be Corrected: February 3, 2022
STAFFING: 32250 - RCR s.44(1)(a) - A licensee must ensure that employees responsible for the preparation and delivery of food (a) have the experience, competence and training necessary to ensure that food is safely prepared and handled and meets the nutrition needs of the persons in care.
Observation: There were 3 times when meals were prepared and handled without a staff person who held a valid food safe certificate
Corrective Action(s): Please ensure that there is one staff person present with the valid training to ensure food is safely prepared and handled and meets the needs of the persons in care.
Date to be Corrected: February 3, 2022
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: Snack is provided 2x a day. The snack menu choices were at times limited to 1 food group from the Canada food guide
Corrective Action(s): Please ensure each of the 2 snacks contain at least 2 food groups from the Canada food guide.
Date to be Corrected: March 5, 2022
NUTRITION AND FOOD SERVICES: 37070 - RCR s.62(2)(c)(iii) - A licensee must ensure that each menu provides (c) a variety of foods, taking into consideration (iii) seasonal variations in food.
Observation: The facility is currently following the summer menu, which may present challenges of ensuring the menu can be followed at all times such as the seasonal fruits.
Corrective Action(s): Please ensure the menu provides a variety of foods with consideration of seasonal variations in food.
Date to be Corrected: March 5, 2022
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