PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31070 - RCR s.16(2)(a) - A licensee must ensure that each bedroom, bathroom and common room is lit sufficiently to (a) permit a person to carry out effectively the types of activities that would be reasonably expected in the ordinary use of the room.
Observation: In one bathroom used by PIC's it was noted that there were 2 burnt out light bulbs in the light fixture and only 1 working bulb causing insufficient lighting
Corrective Action(s): Replace the light bulbs to ensure sufficient lighting
Date to be Corrected: November 5,2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: During inspection it was noted that:
* The stove rings are black, rusty and have burnt on food
* Broken light fixture cover in the laundry room
* Some scratches on the top of a PIC's night stand
Corrective Action(s): Ensure all equipment and furnishings are maintained in good repair
Date to be Corrected: November 5, 2018
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: During inspection it was noted that:
* Window grout and sills in 4 rooms had mold and dirt on them
* In one bathroom next to the toilet there was feces on the wall
* The large tub room had some staining and dirt on the floor tiles and the front of the tub
* The small bathroom toilet had urine on the ring and on the base
* In one bedroom with the vent in the ceiling there is staining on the roof and dust in the vent
* The furnace room has dust on the equipment, the floors and ceiling
Corrective Action(s): Ensure all rooms and common areas are maintained in a safe clean manner
Date to be Corrected: November 19,2018
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: Upon review of 8 staff files 3 had expired Criminal Record Checks
Corrective Action(s): Ensure all staff have up to date criminal record checks
Date to be Corrected: November 12,2018
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: It was noted during inspection that there were:
* Missing signatures on the MAR for October 14-21 for one PIC
* Missing signatures for October 13 all 8 am medications
* 1 missing response for PRN
Corrective Action(s): Ensure the policies for mediation administration are being implemented by employees
Date to be Corrected: November 5, 2018
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: During inspection it was noted that:
* In the freezer in the dining area food was missing dates
* In the large chest freezer there was food not dated and no system for rotating old and new food
* Potatoes and onions not stored in containers in the drawer
* 1 expired condiment in the fridge
* open food in the cupboards to be dated
Corrective Action(s): Ensure food is stored safely
Date to be Corrected: Nov 5, 2018
RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: During the routine inspection it was noted that there was no menu substitution list available for review
Corrective Action(s): Ensure that a record of menu substitutions is kept and available
Date to be Corrected: November 5, 2018
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