LICENSING: 30160 - RCR s.11(1)(b) - A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility (b) the most recent routine inspection record made under section 9 (1)(d) of the Act.
Observation: Last routine inspection was not displayed at required.
Corrective Action(s): Please ensure to display the most recent routine inspection in a prominent place.
Date to be Corrected: This was corrected on day 1 of the inspection.
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: In a review of 4 employee files, one did not contain evidence of their training/diploma.
Corrective Action(s): Please ensure that each employee file contain evidence of the person's training and skills.
Date to be Corrected: Was correct on last day of inspection
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: In a review of 4 employee files, one employee had an incomplete record of compliance with the Province's immunization program.
Corrective Action(s): Please ensure that a person in not employed until the facility has obtained evidence of compliance with the Province's immunization and tuberculosis control programs.
Date to be Corrected: August 15, 2021
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: In a review of 4 employee files, one employee who is required to, did not have evidence of a valid first aid and CPR certificate.
Corrective Action(s): Please ensure that all staff who are required to hold a valid first aid and CPR certificate provide evidence to ensure that all person in care have access to staff with the required certificates.
Date to be Corrected: August 16, 2021
STAFFING: 32350 - RCR s.92(2) - A licensee must keep for at least 5 years all signed original forms authorizing criminal record checks to be done.
Observation: In review of 4 employee files, one did not contain the original signed forms authorizing a criminal record check to be done.
Corrective Action(s): Please ensure that all original signed CRC authorization forms are retained for 5 year for all employees.
Date to be Corrected: August 15, 2021
CARE AND/OR SUPERVISION: 34670 - RCR s.81(3)(e)(i) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (i) an assessment of the nature of the risk of falling presented by the person in care.
Observation: Two persons in care were described as being at risk for falls and measures in place such as hip protectors, footwear and adjusted bed height, however there risk for falls and a plan to prevent them was not reflected in their care plans as required
Corrective Action(s): Please ensure that for a person who may at risk for fall, a fall prevention plan be included in their care plan.
Date to be Corrected: August 15, 2021
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: For one person in care, a change had been made in the required consistency of their food, however this was not updated on their care plan as required.
Corrective Action(s): Please ensure that if there is a substantial change in the care required, that the care plan is up to date.
Date to be Corrected: August 2, 2021
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: It was observed that consistent records were not maintained for the monitoring of the food services fridge and freezer temperatures. At the time of the inspections, none of the records had been signed for in the past week.
Corrective Action(s): Please ensure that a record is kept for matters respecting food services.
Date to be Corrected: August 15, 2021
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