Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
25-Jul-2022
Subject
["Staffing (Includes issues such as suitability, insufficient levels, etc.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must ensure that each menu provides for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada’s Food Guide,
Observation: Through the investigation process, Licensing determined that the Licensee did not ensure that each menu provided for each day, at least two nutritious snacks, with each snack containing at least two food groups.
Corrective action: Ensure that each menu provided for each day, at least two nutritious snacks, with each snack containing at least two food groups. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 19, 2023, Licensee submitted a corrective action plan to Licensing. This corrective action plan included a copy of the new snack menu. This corrective action plan was reviewed and accepted by Licensing.
A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of the persons in care,
Observation: Through the investigation process, Licensing determined that the Licensee did not ensure that, at all times, the employees on duty were sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of persons in care.
Corrective action: Ensure that, at all times, there are employees on duty in sufficient numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 19, 2023, Licensee submitted a corrective action plan to Licensing. This corrective action plan included information on ongoing recruitment and hiring of sixteen staff. This corrective action plan was reviewed and accepted by Licensing. On June 28, 2023, Licensee submitted an update that in August 2022, they increased care aides from six to eight on days and evenings, added an additional culinary evening shifts in October 2022 and one additional housekeeper on weekends in August 2022. Licensing observed these additional staffing during Routine Inspections at the facility.
A Licensee must do all of the following: operate the community care facility in a manner that will promote the health, safety and dignity of persons in care.
Observation: Through the investigation process, Licensing determined that the Licensee did not operate the community care facility in a manner that promoted the health, safety and dignity of persons in care.
Corrective action: Ensure that the facility operates in a manner that promotes the health, safety and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 19, 2023, Licensee submitted a corrective action plan to Licensing. This corrective action plan included a copy of the staff verification of proof of vaccination. This corrective action plan was reviewed and accepted by Licensing.
A licensee must ensure that a person in care is not, while under the care or supervision of the licensee subjected to any of the following types of abuse or neglect, as described in section 1 of Schedule D: neglect
Observation: Through the investigation process, Licensing determined that the Licensee did not ensure that a person in care was not, while under the care or supervision of the licensee subjected to neglect.
Corrective action: Ensure that a person in care is not subjected to neglect. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 19, 2023, Licensee submitted a corrective action plan to Licensing. This corrective action plan included a plan of ongoing recruitment and active hiring of staff, since July 2022, sixteen staff were hired and employee schedules were reviewed to ensure fewer open lines and if a manager worked on the floor that it was documented on the schedule. This corrective action plan was reviewed and accepted by Licensing.
A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to assist persons in care with activities of daily living, including eating, mobility, dressing, grooming, bathing and personal hygiene, in a manner consistent with the health, safety and dignity of persons in care.
Observation: Through the investigation process, Licensing determined that the Licensee did not ensure that, at all times, the employees on duty were sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of persons in care.
Corrective action: Ensure that there are enough employees on duty who have the training and experience, and are organized in an appropriate staffing pattern, to meet the needs of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 19, 2023, Licensee submitted a corrective action plan to Licensing. This corrective action plan included information on ongoing recruitment and hiring of sixteen staff. This corrective action plan was reviewed and accepted by Licensing. On June 28, 2023, Licensee submitted an update that in August 2022, they increased care aides from six to eight on days and evenings, added an additional culinary evening shifts in October 2022 and one additional housekeeper on weekends in August 2022. Licensing observed these additional staffing during Routine Inspections at the facility.
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 criminal record check for the person
Observation: Through the investigation process, Licensing determined that the Licensee did not employ a person in the community care facility with obtaining a criminal record check.
Corrective action: Ensure that criminal record checks are obtained for employees. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 19, 2023, Licensee submitted a corrective action plan to Licensing. This corrective action plan included a copy of the staff criminal record check result. This corrective action plan was reviewed and accepted by Licensing.
A licensee must do all of the following: ensure that policies are implemented by employees.
Observation: Through the investigation process, Licensing determined that the Licensee did not ensure that policies were implemented by employees.
Corrective action: Ensure that policies are implemented by employees. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On January 19, 2023, Licensee submitted a corrective action plan to Licensing. This corrective action plan included a plan of employees re-educated on how to document and sign off on bath tasks when completed. This corrective action plan was reviewed and accepted by Licensing.