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 (CORRECTED DURING INSPECTION): Inspection of both shower rooms located on the second floor found that the drain covers were missing. During second day inspection is was noted that drains have been fixed.
Corrective Action(s): A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Date to be Corrected:
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 seven staff files found that one only had one reference checked, and a second had no evidence of reference checks.
Corrective Action(s): 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.
Date to be Corrected: 14-Nov-2023
STAFFING: 32083 - RCR s.37(3)(c) - Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Review of seven staff files found that one was missing TB and immunization documentation. Another was missing a TB form which was corrected on site.
Corrective Action(s): Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Date to be Corrected: 14-Nov-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: Review of seven staff files found three to be missing performance reviews.
Corrective Action(s): 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.
Date to be Corrected: 14-Nov-2023
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: Review of seven staff files found one to be missing foodsafe certification.
Corrective Action(s): 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 person in care.
Date to be Corrected: 14-Nov-2023
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Upon inspection of the kitchens located on floor 1, 2, and 3, it was noted that temperatures were being taken and documented. However, when temperatures were found to be out of the safe range, there was no corrective action documented or taken. Also noted was food in the fridges, freezers, and cupboards were not consistently covered, dated, and labelled.
Corrective Action(s): A Licensee must ensure that all food is safely prepared, stored, served and handled.
Date to be Corrected: 14-Nov-2023
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Of six care plans, two were missing one month of weights, and one was missing three months of weights.
Corrective Action(s): Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Date to be Corrected: 14-Nov-2023
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