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: On inspection the LO noted several bedrooms where paint was peeling on baseboards and walls
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair
Date to be Corrected: August 15, 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: On inspection the LO noted several areas in common areas such as the lounge and hallways, and bedrooms and bathrooms had dirty areas of the floor with dust/dirt build up particularly in corners
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: June 15, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: On inspection a tub room that had a "must be locked" notice posted on it, was unlocked with no one inside. Some cleaning chemicals are stored in this room
2 dirty laundry carts were observed to be kept in the hallways of the site. Dirty laundry requires safe storage that is inaccessible to PIC's
Corrective Action(s): Ensure safe storage of all hazardous materials
Date to be Corrected: May 31, 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: Review of 6 employee files found that 1 file had evidence of a local criminal record check. The contract manager confirmed that some employees only have a local criminal record check.
Corrective Action(s): Ensure that all employees have a criminal record completed through the Criminal Records Review Agency.
Date to be Corrected: August 15, 2018
STAFFING: 32270 - RCR s.44(2) - A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is (a) a nutrition manager with membership in the Canadian Society of Nutrition Management, (b) a person who is eligible to be a member of the Canadian Society of Nutrition Management, or (c) a dietitian.
Observation: Discussion with the DOC and review of the employee file of the Food Services Manager found that she does not have a CS & M designation
Corrective Action(s): Ensure that the Food Services Manager on site has a CS & M designation, is eligible for membership or is a dietician
Date to be Corrected: June 30, 3018
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: Review of 5 charts found 1/5 did not include evidence of a TB test or screening
Corrective Action(s): Ensure that all PIC's have evidence of compliance with the Province's TB program
Date to be Corrected: June 30, 2018
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: One bathroom in a PIC's bedroom did not have any towels or paper towels for use in the bathroom. Several other rooms use towels for PIC's in the bathroom, and the areas are marked with PIC names. In two instances 3 PIC's occupy a room but only 2 towels were available. Staff confirmed that the PIC's are not independent and the staff bring extra towels when providing care. Please ensure this system is communicated and understood by all staff.
Corrective Action(s): Ensure that hygiene materials are available for all PIC's
Date to be Corrected: May 15, 2018
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: A new menu is being implemented and was provided to the LO. The DOC confirmed that a menu audit was completed for the menu, but at the time of report writing had not been provided for review by the LO.
Corrective Action(s): Ensure that each week of the menus being used include a menu audit and they are kept on site.
Date to be Corrected: June 15, 2018
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