PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: The hot water was measured to be 50.1°C at the sink in the washroom on the second floor and 49.9°C in the upstairs ensuite. This is a repeat contravention.
Corrective Action(s): Ensure water accessible to a person in care, from any source, is not heated to more than 49°C.
Date to be Corrected: June 9, 2022
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: The corner walls located near the balcony had 6-7 paint chips exposing the inner wall.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: July 3, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Disinfectants and chemicals were stored under the washroom sink making it accessible for PIC.
Corrective Action(s): Ensure that cleaning agents, chemical products and other hazardous materials are safe and securely stored.
Date to be Corrected: July 3, 2022
STAFFING: 32030 - RCR s.37(1)(c) - 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: (c) a record of the person's work history.
Observation: Review of 2 of 5 employee files found no evidence of work history.
Corrective Action(s): Ensure to obtain a record of the person's work history.
Date to be Corrected: July 3, 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 2 of 5 employee files 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: July 3, 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: No evidence of policies and procedures being reviewed once a year as evidence by last revision date in 2017.
Corrective Action(s): July 3, 2022
Date to be Corrected: Review and if necessary, revise policies and procedures at least once a year.
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: A review of their medication cabinet found three medications passed expiry date. This is a repeat contravention.
Corrective Action(s): Ensure expired medications are returned to the pharmacist.
Date to be Corrected: July 3, 2022
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: A review of the site's Week 3 Menu found fewer daily servings of fruits/vegetables and grains than recommended as per Canada's Food Guide. Management indicated that menus are in the process of revision. This is a repeat contravention.
Corrective Action(s): Ensure all menus offer the minimum number of required servings based on the Canada Food Guide.
Date to be Corrected: July 3, 2022
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: Review of 1 of 4 PIC's weight charts determined that a weight was not captured for the month of April and there was no documentation provided to explain why the weight was missing.
Corrective Action(s): Ensure that each person in care is weighed at least once a month or provide a reason as to why the weight could not be obtained.
Date to be Corrected: July 3, 2022
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