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: Licensing observed the following concerns:
- Dinning rooms had paint chips and scuffs on walls, cupboards, and window ledges ranging from 3 cm to 9 cm in length. All dinning rooms were affected.
- Algae and moss were present on the PIC patio, exterior of the building, and the roof.
- One bedroom window screen had two holes of approximately 6” x 4” in size.
Corrective Action(s): Ensure rooms and common area are maintained in a good stated of repair.
Date to be Corrected: May 31, 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: A criminal record check had not been obtained for one staff person prior to employment.
Corrective Action(s): Ensure criminal record checks are obtained prior to employment.
Date to be Corrected: March 23, 2022
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: The refrigerator for medical samples was 10.7 and 9.8 degrees Celsius as measured at different times during the inspection. As per policy the refrigerator temperature should remain between 4 and 8 degrees Celsius.
Corrective Action(s): Ensure MSAC policy and procedures are followed.
Date to be Corrected: March 22, 2022
POLICIES AND PROCEDURES: 33080 - RCR s.51(2) - A licensee must ensure that the plans described in subsection 51(1) are updated if there is any change in the facility
Observation: Emergency plans contained outdated contacts. Documents in the emergency plans had dated reviews of 2019 or older.
Corrective Action(s): Ensure the emergency plan is current.
Date to be Corrected: April 30, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation (CORRECTED DURING INSPECTION): Licensing observed dry goods stored on the ground for a period of greater than two hours.
Corrective Action(s): Ensure food is stored safely.
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37105 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation: The four week menu was displayed in two of the four dinning rooms. One menu displayed was the Summer 2021 menu; however, this menu was replaced for the current menu during the inspection.
Corrective Action(s): Ensure weekly menus are displayed in each dinning area.
Date to be Corrected: April 30, 2022
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