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: Review of the physical facility found the following:
- The outside of the entry door and frame are chipped and scratched around the bottom and the door handle.
- There are multiple walls inside the facility that are chipped down to the gyprock.
Corrective Action(s): Please ensure that the facility is maintained in a good state of repair.
Date to be Corrected: September 17, 2019
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: Review of the physical facility found the following:
- The outside entryway has cobwebs around the door and planters. You have to stand to one side in order to not walk into them.
- The back deck has cobwebs around the rails
- There was a cobweb hanging down outside of a person in care's (PIC) room.
Corrective Action(s): Please ensure that the physical facility in maintained in a clean condition.
Date to be Corrected: September 3, 2019
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: Review of 5 employee files found the 4 files did not contained character reference checks.
Corrective Action(s): Please ensure that character reference checks are obtained for each employee.
Date to be Corrected: September 3, 2019
STAFFING: 32030 - RCR s.37(1)(c) - 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: (c) a record of the person's work history.
Observation: 1 out of 5 employee files did not contain a resume.
Corrective Action(s): Please ensure that a resume is obtained for each employee.
Date to be Corrected: September 3, 2019
STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: On the first day of inspection the manager was not available. 2 of the employees assisting in the inspection were questioned as to how food would be provided for 1 PIC who required a tube feed as there was no tube feed in the emergency supplies; staff did not know. The manager indicated on the second day of the inspection that staff were to remove a case of the feed that is stored in the same storage room.
Corrective Action(s): Please ensure that all employees are trained in the implementation of the emergency plan and that supplies are easily accessible in the case of an evacuation.
Date to be Corrected: September 17, 2019
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: Review of policy and procedures found that they have not been reviewed and/or update since 2017.
Corrective Action(s): Please ensure that policies and procedures are reviewed, and if necessary, revised at least once each year.
Date to be Corrected: September 17, 2017
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: Review of monthly fire drills found that they were not completed in April and May. The policy requires that they are completed monthly.
Corrective Action(s): Please ensure that employees implement all policies and procedures.
Date to be Corrected: September 3, 2019
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Review of the food in the facility found the following:
- There were 2 food items in the fridge that were not labelled.
- There was a box of expired breakfast drink in the emergency supplies. Staff removed this from the emergency supplies at the time of inspection.
Corrective Action(s): Please ensure that food is safely stored and served.
Date to be Corrected: September 3, 2019
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: Review of the menu audit found the following:
- On days 1 & 5 the minimum servings for grains is not being met
- On days 2 & 6 the minimum servings for fruits and vegetables is not being met
- On day 7 the minimum serving for dairy is not being met.
Corrective Action(s): Please ensure that each person in care receives adequate food to meet their personal nutritional needs based on Canada's Food Guide.
Date to be Corrected: September 17, 2019
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