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: Observations:
1). The sliding door screen in 1 PIC's bedroom on the upper level was broken.
2). 1 PIC's bedroom has the chair scruffs and scratch on the wall measuring approximately 10cmx2cm exposing the drywall.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: October 29, 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: All wall mounted fire extinguishers at the facility are overdue for service. The staff assisting with the inspection on Day 1 was not aware of the service of fire extinguishers and informed the Licensing officer that the maintenance Manager is away at present.
Corrective Action(s): Please ensure that all emergency equipment and monitoring devices are inspected, serviced and maintained in working order on a regular basis.
Date to be Corrected: September 30, 2021
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: Bleach and other cleaning agents were found on top of the counter in the laundry room. The door to the laundry room can be shut but is not lockable however staff have cupboards in the laundry room that have locks where these chemicals can be safely stored.
Corrective Action(s): Please ensure that all cleaning agents, chemical products and hazardous materials are securely and safely stored at all times.
Date to be Corrected: September 30, 2021.
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 (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: A review of the staffing requirement summary found that 1 casual employee's last performance review was conducted in 2008 and 2 employees' performances were last reviewed in 2017 and 2018. Except for the 2 newer staff, there is an inconsistency in the annual performance reviews of the remaining staff.
Corrective Action(s): Please ensure that each staff's performance is reviewed to demonstrate the competence required for the assigned duties.
Date to be Corrected: October 29, 2021
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: A review of the Medication Administration Records found that 1PIC's PRN medication records had no entry for results on August 15, 2021 and 1PIC's PRN medication records had no entry for results on August 22, 2021.
Corrective Action(s): Please ensure that staff comply with the policies and procedures of the MSAC.
Date to be Corrected: September 30, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: A review of fridge and freezer temperature logs found inconsistent recording of the temperatures as 1 smaller fridge/freezer and the main kitchen freezer temperature was not recorded at all.
Corrective Action(s): Please ensure appropriate temperature is maintained for all fridge and freezers for storing food safely and that staff are documenting this appropriately as well.
Date to be Corrected: September 30, 2021
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: A review of the substitutions listed found that on June 29 a mushroom burger was substituted with Chicken, soup and salad. A discussion with the staff person assisting with the inspection found that the lunch served was not the same as the menu because staff use leftovers as well and the Licensing Officer found that menu substitution list was not completed to denote the same.
Corrective Action(s): Please ensure that menu substitutions are from the same food group and have a similar nutritional value and that staff are completing this document appropriately.
Date to be Corrected: September 30, 2021
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: Review of the incident reports found 1 PIC had an unexpected illness on April 26, 2021 and no notification was submitted to Licensing officer.
Corrective Action(s): Please ensure that notification for all reportable incidents involving PICs are immediately sent to the Licensing officer in the form and in manner required by the Medical health Officer.
Date to be Corrected: September 30, 2021
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