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: Licensing observed the following concerns:
- Chipped paint on walls in 3 out of 3 dinning rooms. Each room had greater than 10 chipped sections up to 4” in diameter.
- Dented walls and poles in 3 out of 3 dinning rooms with areas up to 6” in diameter.
- Sections of baseboards missing in two PIC rooms/bathrooms ranging from 2’ to 6’ in length.
- An approximately 2’ section of vanity was missing in one PIC’s bathroom.
- Damage to walls in two PIC’s rooms (approximately 24” x 1” and 48” x 2”,respectively)
(This is a repeat contravention from Routine Inspection AKUR-BLCHFB dated January 30, 2020).
Corrective Action(s): Ensure rooms and common area are maintained in a good stated of repair.
Date to be Corrected: May 31, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: Fire extinguishers and emergency lighting throughout the facility were past the required inspection date of January 20, 2022. The first aid supplies included in the emergency kit contained expired alcohol wipes and wound irrigation solution.
Corrective Action(s): Ensure regular inspections and maintenance of emergency equipment.
Date to be Corrected: March 8, 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: Four out of ten staff files did not have performance reviews completed as per the licensee’s policy.
Corrective Action(s): Ensure regular reviews of employee performance are completed.
Date to be Corrected: April 15, 2022
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Four policies had not been reviewed in one year or more including Falls Management policies.
Corrective Action(s): Ensures policies are reviewed once a year.
Date to be Corrected: May 1, 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: Documentation was not available to demonstrate staff implemented falls/head injury policies for one Person in Care (PIC). Documentation was not available to demonstrate the Dietician was made aware of a PIC's weight change as per the terms and conditions of their care plan.
Corrective Action(s): Ensure policies and procedures are implemented by employees.
Date to be Corrected: March 4, 2022
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: Nine Persons in Care were not listed on the Diet and Noursihment list (This is a repeat contravention for Routine Inspection AKUR-BLCHFB dated January 30, 2020).
Corrective Action(s): Ensure the implementation of each care plan is monitored on a regular basis.
Date to be Corrected: March 4, 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: Valid criminal record checks were not on file for three staff.
Corrective Action(s): Ensure a record of staff’s criminal record results are kept
Date to be Corrected: March 4, 2022
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: Records of menu substitutions were not available since July 2021.
Corrective Action(s): Ensure record of menu substitutions is kept.
Date to be Corrected: March 4, 2022
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