LICENSING: 30160 - RCR s.11(1)(b) - A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility (b) the most recent routine inspection record made under section 9 (1)(d) of the Act.
Observation: The most recent licensing routine inspection was not displayed within the facility, as required. This is a repeat contravention from the 2019 routine inspection.
Corrective Action(s): Please ensure the most recent routine inspection is displayed in a prominent place in the community care facility.
Date to be Corrected: May 28, 2021
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: It was observed that throughout the facility there were many areas with deep drywall damage , that appeared to be from repeated contact with a wheelchair, and/or other equipment. In many areas of the facility the damage was located in the bedrooms, under the window, just above the baseboard. Of concern is the ability to clean the area due to the depth of damage into the drywall. One bedroom was missing 3 panels on the vertical blind, making it difficult to block out light, and maintain privacy. A bedroom door had large chunks of paint peeling off, making it difficult to clean.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: For 3 of 6 person in care, The information transferred from the care plan to the ADL sheet was inconsistent in guiding staff to provide care.
Corrective Action(s): Ensure the care and supervision of a person in care is consistent with he terms and conditions of the person in care's care plan.
Date to be Corrected:
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 6 person in care (PIC) charts, found that one person in care had an immunization form in their chart that had not been filled out or completed. Another persons in care's immunization form did not have the facility portion of the form completed and signed.
Corrective Action(s): Ensure all persons admitted to the community care facility comply with the Province's immunization and TB control program.
Date to be Corrected: June 4, 2021
RECORDS AND REPORTING: 39440 - RCR s.86(d) - A licensee must keep the following records in respect of each employee: (d) a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.
Observation: The facility did not have a record or evidence of the dates performance reviews were most recently completed for all staff of the facility.
Corrective Action(s): Please ensure the facility has a record of the dates performance reviews were last completed for each employes, following the facility policy for annual review of each employee.
Date to be Corrected: Please submit an action plan to licensing, outlining a plan for correction by June 8, 2021.
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