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 common areas and hallways:
-on 9 care floors a large number of hallway doors and trim are missing paint, with a many scrapes/chips of varying sizes and a number of black marks/scuffs.
- common areas of P2 and P3 (Pointe) there are 5 or 6 locations where the walls have missing paint and holes/chips of varying sizes.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: March 31, 2022
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: Review of 10 employee files, 2 of 10 do not have character references completed.
Corrective Action(s): Please ensure that character references are obtained for all employees.
Date to be Corrected: March 31, 2022.
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: Review of 10 employee files, 2 of 10 have an expired Food Safe Certificate, which is a requirement of their position.
Corrective Action(s): Ensure to obtain copies of diplomas, certificates or other evidence of the person's training and skills.
Date to be Corrected: March 31, 2022
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: Review of 10 Employee Files, 2 of 10 did not have a Performance Review completed within 3 years, per facility policy.
Corrective Action(s): Ensure that performance of each employee is reviewed regularly to ensure that the employee continues to meet the requirements of this regulation.
Date to be Corrected: March 31, 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: Review of 10 employee files, 1 of 10 had a first aid and CPR certificate that expired in July 2020.
Corrective Action(s): Ensure that all staff who require First Aid and CPR certification have a current/valid certificate.
Date to be Corrected: March 31, 2022
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: Review of 9 charts for Persons in Care , 4 of 9 did not have current annual recreation assessments and 2 of 9 did not have initial or annual recreation assessments completed, per the facilities Recreation Documentation policy.
Corrective Action(s): Please ensure that policies are implemented by employees.
Date to be Corrected: March 31, 2022
RECORDS AND REPORTING: 39410 - RCR s.86(a) - A licensee must keep the following records in respect of each employee: (a) criminal record check results,.
Observation: Review of 10 employee files, 1 of 10 files had a Criminal Record Check that expired in 2015.
Corrective Action(s): Ensure that current results for criminal record checks are kept in employee files/records.
Date to be Corrected: March 31, 2022
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