LICENSING: 30150 - RCR s.11(1)(a) - 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 (a) both the licence, including any terms or conditions of the licence, and the name of the manager.
Observation: During physical inspection it is noted that the licence is not displayed in the facility.
Corrective Action(s): Ensure that both the licence, including any terms or conditions of the licence, and the name of the manager are posted in a prominent place in the facility.
Date to be Corrected: May 31, 2022
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: During physical inspection it is noted that the most recent routine inspection record is not displayed in the facility.
Corrective Action(s): Ensure that the most recent routine inspection record is displayed in a prominent place.
Date to be Corrected: May 31, 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: During physical inspection it is noted:
In the common areas and hallways the wainscotting and many doors,doorway and trim have scrapes, grooves and black marks on them.
5 of 7 resident rooms it is noted the drywall has scuffs, dents and paint chipping off.
4 of 7 resident rooms have blinds that are broken or missing slats.
Corrective Action(s): Ensure that all resident rooms and common areas are maintained in a good state of repair.
Date to be Corrected: May 31, 2022
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 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Employee files are kept offsite and during discussion with the site manager on how the team tracks and manages performance reviews, the manager confirmed that performance reviews for employees are not current and have not been completed since 2019.
Corrective Action(s): Ensure that performance of employees is reviewed both regularly and as directed by the medical heath officer.
Date to be Corrected: May 31, 2022
STAFFING: 32260 - RCR s.44(1)(b) - A licensee must ensure that employees responsible for the preparation and delivery of food (b) receive ongoing education respecting the preparation and delivery of food, nutrition and, if required, assisted eating techniques.
Observation: During discussion with the staff it was confirmed that the care team has not had recent training with respect to assisted eating techniques.
Corrective Action(s): Ensure that employees responsible for the preparation and delivery of food receive ongoing education respecting the preparation and delivery of food, nutrition and, if required assisted eating techniques.
Date to be Corrected: May 31, 2022
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Upon review of the 4 week menu posted, it is noted that there is a rotation of 3 different soups through the 4 week period. In discussion with staff it was stated that persons in care receive broth at meals if they do not like or cannot have the soup of the day.
Corrective Action(s): Ensure that each menu provides for substitutions to be made that are from the same food group and have a similar nutritional value.
Date to be Corrected: May 31, 2022
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Review of 6 persons in care charts, 4 of 6 charts did not have evidence of consent in writing to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Corrective Action(s): Ensure that each person in care's record has consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Date to be Corrected: May 31, 2022
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