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: The common area door frame has the plastic baseboard sticking out requiring reattachment. The persons in care's bedroom door and door frame have scuffs and chips.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in good state of repair.
Date to be Corrected: October 31, 2022
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: Three of 5 staff files did not have the evidence of compliance to Province's immunization and TB on file.
Corrective Action(s): Please ensure that all employees in a community care facility provide evidence of compliance to Province's immunization and tuberculosis control programs.
Date to be Corrected: September 8, 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: The licensee's policy and procedure requires that staff's performance appraisals are completed annually. One of 5 staff had the last performance appraisal in 2020.
Corrective Action(s): Staff performance appraisal must be completed according to Licensee's policy and procedure.
Date to be Corrected: September 8, 2022
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: Licensee's policy and procedure requires that all employees working directly with children or adults are expected to possess Standard First Aid Certification and training in Cardiopulmonary Resuscitation (CPR). One of 5 staff does not have first aid and CPR certificate on file.
Corrective Action(s): A licensee must ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate.
Date to be Corrected: September 8, 2022
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: The emergency bins does not contain the necessary supplies as listed in the facility emergency food supplies.
Corrective Action(s): A licensee must have an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Date to be Corrected: September 8, 2022
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: Three of 5 persons in care has no evidence of compliance to Province's immunization and tuberculosis control programs on file.
Corrective Action(s): A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: September 30, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation (CORRECTED DURING INSPECTION): Three bottles of dressing past its best before date stored in the kitchen pantry.
Corrective Action(s): A licensee must ensure that all food is safely stored.
Date to be Corrected: August 22, 2022
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Review of the menu and nutrition monitoring records found to be missing the menu audit/checklist.
Corrective Action(s): Please ensure a record of nutritional monitoring, with respect to menu auditing, is kept.
Date to be Corrected: September 8, 2022
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