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: Throughout the facility in both bedrooms and common areas, it was observed that the base board heaters had areas that were: falling apart, missing pieces, and loose. In one common area the pipe connecting to the baseboard heaters had fallen out of the brackets and was resting on the floor. In one bedroom there were wires from the baseboard heater exposed. Near a nursing station there was trim missing from one window with some nails exposed (window looking into a staff area/ med room).
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair. In discussion with the maintenance manager, the manager will put together a plan to review and repair, and submit to licensing.
Date to be Corrected: Please submit plan to licensing by April 9, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31850 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation (CORRECTED DURING INSPECTION): It was observed that in one dining area the weekly menu was not posted.
Corrective Action(s): Corrected on inspection.
Date to be Corrected:
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: On review of 8 staff files, 2 staff files were missing evidence that the required training had been completed.
Corrective Action(s): Ensure all staff files contain, copies of any diplomas, certificates, or other evidence of the persons training and skills.
Date to be Corrected:
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: On review of 8 staff files, the immunization form for one staff member, did not have the employer portion of the form completed.
Corrective Action(s): ensure the manager has obtained evidence that all staff have complied with the Province's immunization and TB control programs.
Date to be Corrected:
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: On review of 8 staff files one staff member did not have a performance review completed in the last 3 years, as required by the facilities policy.
Corrective Action(s): Ensure that the performance of each employee is reviewed both regularly and as directed by the MHO to ensure the employee continues to meet the requirements of this regulation.
Date to be Corrected:
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation (CORRECTED DURING INSPECTION): On review of 8 person in care (PIC) files:
- for 3 files reviewed, the employer portion of the TB form was incomplete
- for 2 files reviewed, the employer portion of the immunization form was incomplete
Corrective Action(s): Ensure all persons admitted into care, comply with the Province's immunization and TB control program.
This was corrected by day 2 of the inspection.
Date to be Corrected:
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: It was observed that 3 items stored in the fridge / freezer, had been removed for the original packaging, and did not contain the date opened.
The resident fridge contained 3 items that were not labelled with the person in care's name or date placed in the fridge. (these items were discarded on inspection).
Corrective Action(s): Ensure that all food is safely prepared, stored, served and handled.
Date to be Corrected:
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