LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: A review of the care planning system and persons in care charts indicated that on the Monthly Weight, Blood Pressure and Pulse document that for 1 particular month there is no staff initial. Specifics were provided during the inspection.
Corrective Action(s): Please ensure the care and services provided by the facility are regularly monitored to ensure that the requirements of the Community Care and Assisted Living Act & Residential Care Regulation are being met.
Date to be Corrected: March 30, 2022.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: A random review of the hot water temperature at person(s) in care ensuite washroom sinks indicated that at a ensuite washroom sink the reading was 50.2 degrees Celsius and slowly increasing. The Manager stated Facilities Management did address this after the Licensing Officer completed the routine inspection in October 2021.
Corrective Action(s): Please ensure the water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Date to be Corrected: March 30, 2022.
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: The items noted in the routine inspection report still need to be completed/addressed.
The Manager stated the kitchen servery countertops are planned to be replaced. Please review the scope of work for this and please submit a health and safety plan if the day to day operation/routines for the persons in care will be disrupted.
The Manager stated the handrails will be proposed to be removed. The Licensing Officer discussed building code requirements for example and that the Licensing Officer will review this internally as well and get back to the Manager.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: May 31, 2022.
RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: A review of the care planning systems and persons in care charts indicated for a person in care that their weight and height upon admission was not documented.
Corrective Action(s): Please ensure the height and weight of each person in care is recorded upon admission.
Date to be Corrected: March 30, 2022.
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