LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: The HCA Care Flow Sheets noted with 4 dates during "day" shift not initialed by the staff (Specifics provided during the inspection).
Corrective Action(s): Please ensure the care and services provided by the facility are regularly monitored to ensure that the requirements of the Community Care and Assisted LIving Act and Residential Care Regulation are being met.
Date to be Corrected: November 4, 2022.
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: A random check of the hot water temperature at the ensuite washroom sinks indicated the following temperatures:
- 51.4 degrees Celsius at one ensuite washroom sink,
- 50.1 degrees Celsius at one ensuite washroom sink,
- 51.3 degrees Celsius at one ensuite washroom sink.
Corrective Action(s): Please ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Date to be Corrected: November 2, 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: A walkthrough of the facility indicated the following, for example:
- The bathing room across the Residential Care Coordinator's office noted with pooling of water due to the uneven surface which Maintenance Staff have been made aware of. In addition, the door trim to this bathing room noted with paint chipped off/scuff marks in several areas.
- Handrails in various areas with paint chipped off in several areas throughout the facility and the walls above the handrails with scuff marks/chips in the walls throughout the facility.
In addition the items noted in routine inspection report #CRAU-C86NXT dated October 25, 2021 and the Follow-Up Inspection Report #CRAU-CCYV92 dated March 29, 2022 (follow-up to the October 25, 2021 routine inspection report) are in progress of being completed as per the Manager. The kitchen servery countertops have been since installed, however dates for example when these were going to be installed, the Licensing Officer was never made aware. Please in the future advise your Licensing Officer of all information before commencing work (a health and safety plan was submitted, however it was pending approval for example when definitive dates for completion of this work would be sent to the Licensing Officer).
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: January 2023.
RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: In review of the care planning system, it was noted the height for a person in care was not recorded upon admission.
Corrective Action(s): Please record the height and weight of each person in care upon admission.
Date to be Corrected: November 4, 2022.
RECORDS AND REPORTING: 39480 - RCR s.87(d) - A licensee must keep a record of the following matters respecting food services: (d) food services and nutrition care education and training programs attended by food services employees.
Observation: Education and training is occuring on a regular basis, however it is currently not being documented.
Corrective Action(s): Please ensure a record is kept of the food services and nutrition care education and training programs attended by food services employees.
Date to be Corrected: November 4, 2022.
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