PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: An inspection of the physical facility found that two night tables for use by person in care were missing their locks.
Corrective Action(s): Ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair.
Date to be Corrected: August 3, 2021
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 a window screen in one of the tub rooms to be dislodged and bent which requires repair or replacement and found that bedroom doors throughout the facility are missing paint (as a result of signs being tape on them and then removed) which requires painting.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: August 30, 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 of the physical facility found an exposed live wire on the second floor that used to be connected to a video camera (corrected immediately during inspection). Additionally, it was observed that the pathways in the garden off the first floor had three places where tree roots have grown under the path that have now buckled the path creating a potential tripping hazard. Additionally, there are four places on the path where the paving stones are uneven and sunken by approximately 2.5 cm also creating a potential tripping hazard.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: August 30, 2021
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: A review of staff files found that six employee files did not have evidence of character references on file.
Corrective Action(s): Ensure that all persons employed at community care facility have character reference checks completed prior to employment.
Date to be Corrected: July 12, 2021
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 review of staff files found that four employees did not have evidence of required registrations on file (corrected during inspection) and that four employees did not have evidence of required current First Aid/CPR training. Additionally, one employee did not have evidence of required current Food Safe Training.
Corrective Action(s): Ensure that employee files contain copies of any diplomas, certificates, and/or other evidence of the person's training and skills.
Date to be Corrected: August 30, 2021
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 (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: A review of staff files found that six employees did not have evidence of a current performance evaluation on file.
Corrective Action(s): Ensure that the performance of each employee is review both regularly and as directed by the medical health office under subsection (2) to ensure that the employee (b) demonstrates the competencies required for the duties to which the employee is assigned.
Date to be Corrected: August 30, 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 all persons in care and staff for three days in the event of an emergency.
Corrective Action(s): Ensure that an emergency plan sets out procedures to prepare for, mitigate, respond to and recover from any emergency including procedures for the evacuation of persons in care.
Date to be Corrected: August 3, 2021
CARE AND/OR SUPERVISION: 34220 - RCR s.56(1) - A licensee must ensure that a person in care who leaves a community care facility for a temporary purpose has in his or her possession written documentation indicating the person in care's name, the community care facility's name and emergency contact information.
Observation: A review of care plans found that nine persons in care did not have written documentation available to indicate the person in care's name, the community care facility's name, and emergency contact information to identify the person in care when the person in care leaves the facility for a temporary purpose.
Corrective Action(s): Ensure that each person in care has written documentation in their possession indicating the person in care's name, the community care facility's name, and emergency contact information to identify the person in care when the person in care leaves the facility for a temporary purpose.
Date to be Corrected: August 3, 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 care plan called for the person in care (PIC) to wear hip protectors and required the PIC's bed to be in the lowest position; however, it was observed that the PIC was not wearing hip protectors and that the PIC's bed was not in the lowest position. Additionally, the same PIC's room had a fall mat in place which was not noted in the PIC's care plan. Another PIC's care plan called for the PIC to wear hip protectors; however, the PIC was not found to be wearing them. Additionally, another PIC's care plan called for the PIC to be wearing appropriate footwear; however, the PIC was observed be in a common area without any shoes on.
Corrective Action(s): 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.
Date to be Corrected: July 13, 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 seven employees did not have evidence of tuberculosis screening and five employees did not have evidence of immunization records.
Corrective Action(s): Ensure that all employees provide evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Date to be Corrected: August 30, 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: A review of admissions records for persons in care found that three persons in care had incomplete immunization records and one person in care had an incomplete 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: August 3, 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 a fridge on the first floor found that the food stored in it was not labelled or dated (corrected during inspection).
Corrective Action(s): Ensure that all food is safely stored.
Date to be Corrected: June 25, 2021
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