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: 1). The lower part of most walls in hallways have paint chipped off exposing drywalls and there is evidence of wheelchair scruff marking on the walls around the bathroom and bedroom doors.
2). 1 security alarm keypad near the kitchen has come off the wall and is now placed in a ziplock bag hanging on the wires.
Corrective Action(s): Please ensure all common areas are maintained in good state of repair.
Date to be Corrected: October 17, 2022
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: 2 special chairs are stored outside in the back patio (in front of exit door from a bedroom). Of concern is PIC's use of the outdoor space and hazard during an emergency situation. A wheelchair that was stored there was removed after day 1 of the inspection.
Corrective Action(s): Please ensure that common areas are maintained in safe condition.
Date to be Corrected: October 17, 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: 1/8 staff checklist records reviewed had expired criminal record check. The staff assisting with the inspection informed the LO that a follow up will be completed to determine if any record has been received.
Corrective Action(s): Please ensure that all employees present in the facility must have a copy of current CRC on file and provide a safety plan until the CRC is completed in the interim for this staff.
Date to be Corrected: October 17, 2022
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: 3/8 staff checklist records provided had expired foodsafe certifications. The staff assisting with the inspection was unable to confirm if the staff have submitted their current certifications.
Corrective Action(s): Please ensure policies are implemented by employees and that there are systems in place to receive and update staffing records appropriately.
Date to be Corrected: October 17, 2022
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: 2/5 PIC's care plan did not include the latest updates regarding the manner in which they take their medications. Staff were aware of the changes and there were some notes to identify this change on MAR sheets however, the care plan documents were missing the updates.
Corrective Action(s): Please ensure that each care plan is reviewed annually and modified with any substantial change in the circumstances of the PIC.
Date to be Corrected: October 18, 2022
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: 2/5 PICs did not have monthly weights recorded for February and May and there was no documentation of reasons for not weighing them on the charts.
Corrective Action(s): Please submit a plan to ensure that each PIC is weighed at least once per month and that reasons for not weighing a PIC are documented appropriately.
Date to be Corrected: October 17, 2022
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