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: During the routine inspection of the physical facility it was noted that in one bedroom there was significant damage to the bathroom door frame, bathroom door, walls of the room and furniture caused by the power wheelchair used by the PIC. It was discussed with staff that the damage was significant and major repairs will be needed, a possible removal of the bathroom door was also discussed.
Corrective Action(s): Ensure repairs are completed and rooms are maintained in good state of repair
Date to be Corrected: December 28, 2020
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: During the inspection of the physical facility it was noted that
- the shared bathing room had mold around the outside of the roof and the fan had dust on it
- the emergency exit stairs do not have the anti slip strips on the stairs
- There was a stand fan in on PIC bedroom with dust on it
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition
Date to be Corrected: December 28, 2020
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: A chemical agent CLR was found in a PIC's room unsecured. removed at the time of inspection
Corrective Action(s): corrected
Date to be Corrected: October 28, 2020
STAFFING: 32120 - RCR s.40(3) - A licensee must not permit an employee to carry out any duties for which the employee does not have the necessary training and experience or demonstrate the necessary competence.
Observation: Kitchen staff actions demonstrated lack of knowledge around food safety, handling and preparation
Corrective Action(s): please ensure staff have the necessary training and experience or demonstrate necessary competence
Date to be Corrected: November 28, 2020
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: fire extinguishers and safety light system is out of date
Corrective Action(s): ensure that extinguishers and lights are inspected yearly
Date to be Corrected: November 12, 2020
POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation: emergency food supplies were not sufficient in numbers and variety to meet the needs of the PIC's dietary needs in an emergency. No emergency water was available, and no 3 day emergency menu was available
Corrective Action(s): ensure there is sufficient food water and menu available in the event of an emergency
Date to be Corrected: November 12, 2020
POLICIES AND PROCEDURES: 33100 - RCR s.60(a) - A licensee must (a) establish a fair, prompt and effective process for persons in care and their parents or representatives, family members and contact persons to express a concern, make a complaint or resolve a dispute.
Observation: No policy available for handling concerns or complaints
Corrective Action(s): ensure there is a policy for concerns and complaints
Date to be Corrected: February 28 2020
POLICIES AND PROCEDURES: 33160 - RCR s.74(1)(a) - Subject to subsection (2), a licensee may restrain a person in care (a) if the restraint is necessary to protect the person in care or others from imminent serious physical harm
Observation: No restraint policy available for emergency restraint
Corrective Action(s): ensure all policies are available for review
Date to be Corrected: February 28, 2020
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: REPEAT CONTRAVENTION - no documentation available that the policies have been reviewed or revised
Corrective Action(s): ensure policies are reviewed and revised yearly
Date to be Corrected: Feb 28, 2020
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation:
Inspection of the kitchen and food service facilities noted -
Food in freezer and fridges lacked dates and labelling
2 condiments in the fridge were expired
Staff food was stored in the kitchen freezer and fridge as well as it was not labeled
Condiments were taken from larger containers and stored in inappropriate smaller containers with no labels or dates
Temperatures were not recorded for a resident fridge and staff room fridge
Pre-poured and uncovered milk and juice was in the fridge
Corrective Action(s): Ensure all food is safely prepared, stored, served and handled
Date to be Corrected: November 12, 2020
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