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: Leather couch in the video game room had arm rests both ripped measured 12 cm x 5 cm and 7 cm x 6 cm and more than 10 surface cracks on top cushion. Disks cabinet has misaligned door, not closing properly. Computer table in the dining area was missing the edge trim exposing the rough edges of the wood approximately measures 2 feet. Three of the laundry cabinets were missing cabinet handles. Recreation room couch had two cushions ripped. Laundry table used to folding clothes had the corners chipped and cracked.
Corrective Action(s): Please ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair.
Date to be Corrected: May 11, 2022
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: A fire extinguisher that required inspection was 6 months overdue for a service.
Corrective Action(s): Please ensure that equipment are inspected and maintained on a regular basis.
Date to be Corrected: May 11, 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: One of the eight staff files did not have a valid criminal record check on file.
Corrective Action(s): It is a requirement that a Licensee obtains a valid criminal record check for an employee prior to working with vulnerable persons and existing employees must renew an existing criminal check every 5 years. Employees without a valid criminal record check must not work with persons in care. Please provide a Health and Safety Plan immediately for employee that does not currently have a valid criminal record check.
Date to be Corrected: May 11, 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: PRN medication results were not recorded for 2 persons in care. Medication fridge was missing the temperature gauge and temperature monitoring sheet.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: May 11, 2022
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: The Licensee did not have evidence of reviewing policies and procedures during 2021.
Corrective Action(s): Please ensure that policies and procedures are reviewed and, if necessary, revised once per year.
Date to be Corrected: May 11, 2022
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Sixteen persons in care out of twenty did not have the weight taken for August 2022, no weight taken for twenty PICs for September 2021 and seventeen PICs out of twenty did not have weight taken for October 2021.
Corrective Action(s): Please ensure that each person in care is weighed at least once each month.
Date to be Corrected: May 11, 2022
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