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: An inspection of the physical facility found a patch of flooring in the shower room (approximately 60 cm x 1 cm in size) to be separating where it is supposed to join near the floor drain. Additionally, the fence on the east side of the facility grounds was observed to be missing approximately three boards which requires replacement or repair.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: February 11, 2022
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: An inspection of the physical facility found a drain hole in the sidewalk on the west side of the facility (where it appears a gutter down pipe used to connect) which is missing a cover and which is a potential tripping hazard. Additionally, the facility's rain gutters were observed to have debris sticking out of them which requires cleaning to ensure proper drainage of rain water off the roof.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: January 28, 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 review of staff files found that one out of four reviewed did not have a current criminal record check on file (the last criminal record check had expired on July 13, 2021).
Corrective Action(s): Ensure that a current criminal record check is obtained for each employee prior to employment.
Date to be Corrected: January 26, 2022
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: A review of the facility's emergency supplies found that there was not sufficient water to sustained persons in care and staff for three days in the event of an emergency.
Corrective Action(s): Ensure that an emergency plan sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Date to be Corrected: January 19, 2022
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: A review of admission records for three persons in care found that for one person in care there was no evidence of tuberculosis screening or immunization record on file.
Corrective Action(s): Ensure that all persons admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: January 19, 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: An inspection of the facility's two freezers found three items which were not labelled or dated (this is a repeat contravention).
Corrective Action(s): Ensure that all food is safely stored.
Date to be Corrected: January 7, 2022
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: A review of admission records found that one of three persons in care did not have consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Corrective Action(s): Ensure that written consent from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness is kept with each person in care's record.
Date to be Corrected: January 28, 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: A review of monthly weight records for two out of three persons in care reviewed found that their weights for the month of October 2021 were not recorded and no reason for not obtaining the weights was listed.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: January 19, 2022
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