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: Of 7 bedrooms review, 1 dresser was observed with a drawer that did not close appropriately
Corrective Action(s): Ensure all furniture and equipment for use by persons in care are maintained in a good state of repair.
Date to be Corrected: April 20, 2018
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: Review of the upstairs lounge area for persons in care, the insides of all 6 drawers were peeling and lacked the ability to be cleaned appropriately.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: April 20, 2018.
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: One linen room had blankets stored on the floor of the room.
Corrective Action(s): Ensure all rooms are maintained in a safe and clean condition.
Date to be Corrected: April 20, 2018
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: 1 of 6 staffing files auditted did not contain the employees diploma to confirm evidence of skills and training.
Corrective Action(s): Ensure diplomas, certificates and any other evidence of the staff persons training and skills.
Date to be Corrected: April 20, 2018
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: 3 of 6 staff files auditted, confirmation of compliance with the Province's tuberculosis control programs could not be located. The staff checklists for all files stated that TB compliance was in place.
Corrective Action(s): Ensure licensee maintains evidence on file that the persons has complied with the Province's tuberculosis control programs.
Date to be Corrected: April 20, 2018.
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 (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: 4 of 6 staff files auditted, performance reviews were not completed in the facility's required timeframe.
Corrective Action(s): Ensure the performance of each employee is reviewed regularly to ensure that the employee continues to meet the requirements of this regulation.
Date to be Corrected: April 20, 2018
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: 3 of 3 staff administering medications in one dining room during lunch meal, all at one point left the medication cart unsecured while going to the person in care to administer medications.
Corrective Action(s): Ensure staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: April 20, 2018
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