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: An inspection of the physical facility found that the ceiling in the lower floor bathroom is buckled due to a previous leak and requires repair.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: September 21, 2021
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: An inspection of the facility grounds found that a tree root had been removed in the backyard which has left a trench in the lawn (approximately 2 meters in length by 5 to 7 cm deep) which poses a potential tripping hazard.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: September 7, 2021
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: A review of staff files found that one employee had not had a performance review since 2019.
Corrective Action(s): Ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer to ensure that the employee continues to meet the requirements of this regulation.
Date to be Corrected: September 21, 2021.
CARE AND/OR SUPERVISION: 34080 - RCR s.49(3) - A licensee must assess each person in care on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.
Observation: A review of admission records found that no persons in care had been assessed on admission to determine the risk that they may leave the facility without notification of an employee.
Corrective Action(s): Ensure each person in care on admission is assessed to determine the risk that they may leave the facility without notification of an employee.
Date to be Corrected: September 7, 2021
CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: A review of person in care records found that one person in care had not been examined by a dental health care professional since March 26, 2018 and no evidence was found that this person in care was encouraged to be examined by a dental health care professional at least once every year.
Corrective Action(s): Ensure that persons in care are encouraged to be examined by a dental health care professional at least once every year.
Date to be Corrected: September 21, 2021
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: A review of admission records found incomplete tuberculosis risk assessments and incomplete records of immunization for persons in care.
Corrective Action(s): Ensure that all persons admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: September 7, 2021
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: A review of person in care records found that one person in care did not have written consent 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 the case of accident or illness.
Corrective Action(s): Ensure that each person in care has a 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 the case of accident or illness.
Date to be Corrected: September 7, 2021
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