PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: 1 common area leather couch and a chair (taped) are worn out making it difficult to clean and sanitize.
Corrective Action(s): Please ensure that furniture for use by PICs are maintained in good state of repair.
Date to be Corrected: January 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: The lower part of most walls in hallways and 1/2 shared bathrooms have paint chipped off exposing drywalls and there is evidence of wheelchair scruff marking on the walls around the bathroom doors and the walls.
Corrective Action(s): Please ensure all rooms and common areas are maintained in good state of repair.
Date to be Corrected: July 31, 2022
STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person.
Observation: 2 of 6 staff on the facility staff checklist provided had expired dates recorded for the criminal record check (CRC).
Corrective Action(s): Please ensure that the manager has obtained a CRC for each staff person and recorded it appropriately for Licensing inspections.
Date to be Corrected: January 31, 2022
STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: A performance evaluation had not been completed regularly for all staff. Checklist provided had 1/6 staff performance reviews completed in 2018. The new manager has shared plans to complete evaluations overdue for 2021.
Corrective Action(s): Please ensure that staff’s performance is regularly reviewed.
Date to be Corrected: 31 July, 2022
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation (CORRECTED DURING INSPECTION): A PIC's medication (lotion - to be administered by staff) was found stored in the shared bathroom upstairs.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the MSAC.
Date to be Corrected:
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation (CORRECTED DURING INSPECTION): 2 gallons of cleaning detergents were found stored (unsecured) under the sink in the shared bathroom upstairs.
Corrective Action(s): Please ensure employees implement all policies appropriately.
Date to be Corrected:
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: 2/5 PICs did have any dental examination records on file. The staff assisting with the inspection will schedule appropriate examination for the PICs.
Corrective Action(s): Please ensure PICs are examined by dental care professional annually.
Date to be Corrected: March 31, 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: 2/5 PICs did not have evidence of Province's immunization records. The staff assisting with the inspection had copies of the immunization record forms for the family/doctor to complete.
Corrective Action(s): Please ensure all PICs at the facility comply with the provinces immunization programs.
Date to be Corrected: March 31, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: 3 comb with no identifiers, were observed in a shared bathroom upstairs.
Corrective Action(s): Please ensure that items intended for personal use (to ensure health and hygiene) are not available to others.
Date to be Corrected: January 17, 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: Food items stored in the fridge in the garage did not have any expiry date label. These food items have been removed from the original packaging for easy storage as per staff person assisting with the inspection.
Corrective Action(s): Please ensure that food is safely stored and handled by staff at all times.
Date to be Corrected: January 17, 2022
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