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 five bedroom doors had metal trim that was detached and sticking out from their frames (corrected during inspection). Additionally, a baseboard heater in one bedroom was observed to have its metal covering dislodged exposing sharp coils underneath (corrected during inspection).
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: May 6, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: Two fire extinguishers, both near the facility's kitchen, had inspections that expired in January 2021 (corrected during inspection).
Corrective Action(s): Ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Date to be Corrected: May 6, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: A medication cart was observed to be left unlocked without appropriate supervision.
Corrective Action(s): Ensure that all medications in a community care facility are safely and securely stored (corrected during inspection).
Date to be Corrected: May 6, 2021
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: A review of staff files found that, although 3 staff did have criminal record checks on file, they did not have evidence of criminal record checks on file from the Criminal Records Review Program (CRRP). Upon querying facility staff, it was confirmed that 30+ staff do not have evidence of criminal record checks from the CRRP. Additionally, it was observed that for one staff, although a criminal record check had been applied for through the CRRP, there was no evidence of a criminal record check on file.
Corrective Action(s): Ensure that all persons employed in a community care facility have obtained a criminal record check from the Criminal Records Review Program prior to commencing employment.
Date to be Corrected: May 21, 2021
STAFFING: 32020 - RCR s.37(1)(b) - 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: (b) character references in respect of the person.
Observation: A review of staff files found that two employees hired in the past three years did not have at least two character references on file.
Corrective Action(s): Ensure that a minimum of two character references are obtained prior to employing persons in a community care facility.
Date to be Corrected: May 6, 2021
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: A review of staff files found that two staff did not have evidence of immunization and tuberculosis status.
Corrective Action(s): Ensure that all persons employed in a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: May 21, 2021
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: A review of the facility's emergency supplies found that there was insufficient food to sustain all persons in care and staff for 3 days. Additionally, the emergency water supply was observed to be past its best before date of April 2020.
Corrective Action(s): Ensure that an emergency plan 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: May 21, 2021
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