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: Ceiling portion and wall of tub room on one of the floor has evidence of water type damage. Licensing was provided information to the cause. Hot water for the facility to be made available evening, while the work to address the wall and ceiling completion date is not confirmed at this time.
Corrective Action(s): Please ensure all common areas are in good state of repair.
Date to be Corrected: April 1, 2023
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: One staff was missing their CRC renewal while another staff CRC was for another employer.
Corrective Action(s): Please ensure CRC are all current.
Date to be Corrected: March 31, 2023
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: 14 staff file reviewed, 2 staff yearly review were outstanding, leadership is in the process of completing
Corrective Action(s): Please ensure employee review conducted based on the yearly review policy set by the licensee.
Date to be Corrected: July 30, 2023
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Following observed: 2 PIC's MOST has not been updated. PIC's that have restraint agreement, yearly review process has not been completed.
Corrective Action(s): Leadership provided an update during the inspection that these will be completed during the care conferences which are due coming months.
Date to be Corrected: April 30, 2023
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: 13 PIC files reviewed, 6 had either TB or Immunization information missing or both. Leadership was made aware that one PIC information on the form was updated
Corrective Action(s): Please ensure evidence of PIC's compliance with the TB and immunization is in place.
Date to be Corrected: April 15, 2023
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