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: Throughout the facility it was noted that there are a number or areas that have damage and wear and tear, including the following:
-Damage to wood door frames, entering common areas, and bedrooms
-drywall damage in the dining room (bistro), hallways, and a nursing station
-One kitchenette had a fridge in poor repair, missing a grill, and there appeared to be rust under the fridge and on the floor of the surrounding area.
-One neighborhood that had wood hand rails, had significant wearing of the hand rails, the finish appeared to be worn off, and wood exposed. Of concern is the ability to clean and sanitize the area, and the potential risk of injury.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: Feb 10, 2023
STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Review of 4 staff files found, the facility portion of the immunization screening form was incomplete for 3 staff.
Corrective Action(s): Ensure the facility has evidence that a person has complied with the immunization and TB control program.
Date to be Corrected: Feb 10, 2023
STAFFING: 32360 - RCR s.92(3)(a) - A licensee must keep (a) in the case of employees, all records required under section 37 (1) [character and skill requirements] for the entire time that the subject of the records is an employee of the community care facility.
Observation: 4 staff files were reviewed, and 3 of the 4 files did not contain evidence of the persons training (certificate, diploma, degree).
Corrective Action(s): Ensure the licensee keeps records of an employees character and skill requirements as per RCR 37(1)(d)
Date to be Corrected: Feb 10, 2023
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: For 3 of 5 person in care files reviewed, there had been a change in circumstance, and the care plan had not been updated to reflect the change.
Corrective Action(s): Ensure each care plan is reviewed and if necessary modified, if there is a substantial change in the circumstance of the person in care.
Date to be Corrected: Feb 10, 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: 5 person in care files were reviewed, 1 person in care did not have evidence of a completed immunization screening form.
Corrective Action(s): Ensure that all persons admitted into care, comply with the Province's immunization and TB control programs.
Date to be Corrected: Feb 10, 2023
RECORDS AND REPORTING: 39420 - RCR s.86(b) - A licensee must keep the following records in respect of each employee: (b) character references.
Observation: Review of 4 staff files found, 2 staff did not have any evidence of references checks being completed.
Corrective Action(s): Ensure records are kept in respect of character reference checks.
Date to be Corrected: Feb 10, 2023
|