PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: A dresser had one drawer movable and not closing completely. An over bed table used by PIC has scratches and chips on edges. Two PIC dressers have scratches, chips and uneven top surface. A PIC washroom had slow draining sink. Second floor server countertop has discoloration/stains, sink edges has water damage and top drawer was hard to pull out. A food cart/warmer has stains, chips and dirt around it. Third floor server furniture had one drawer with loose cabinet hinges and water leak damage under the sink causing chipping of the surface measures 8x6 inches. The 2nd floor hallway ceiling has brown discoloration approximately measures 7x4 inches.
Corrective Action(s): Please ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair
Date to be Corrected: April 30, 2023
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: Two bottles of Peroxide disinfectant and cleaner were stored in an unsecured cabinet located in first floor spa and Easy scrub blue cleaner solution was stored in an unsecured cabinet beneath the sink in third floor server furniture. These areas are accessible to persons in care.
Corrective Action(s): Please ensure to have a secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Date to be Corrected: March 18, 2023
STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: One of 12 staff files did not have the evidence of compliance to Province's immunization but only has the tuberculosis test on file.
Corrective Action(s): Please ensure that all employees in the community care facility provide evidence of compliance to Province's immunization control program.
Date to be Corrected: March 18, 2023.
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: The insulin medication has no date when it was opened, this medication has a pharmacy label that can be stored outside the fridge for 28 days. Three Narcotic count sheets found 20 missing second staff signatures.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: March 18, 2023
CARE AND/OR SUPERVISION: 34390 - RCR s.63(5) - A licensee must ensure that persons in care have sufficient time and assistance to eat safely and comfortably.
Observation: During mealtime, a PIC was observed being fed by an employee who was standing. Standing while assisting with feeding does not align with safe feeding practices which minimizes the risk for choking and aspiration. This also does not ensure the comfort of the PIC while eating.
Corrective Action(s): Please ensure that persons in care have sufficient time and assistance to eat safely and comfortably.
Date to be Corrected: March 18, 2023
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: Two of 12 PICs has no evidence of compliance to Province's immunization and tuberculosis control programs.
Corrective Action(s): A licensee must require all person admitted to community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: March 18, 2023
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Two unlabelled pitchers of milk were stored in the third floor refrigerator. An unlabelled plate of food covered with foil was seen on top of the refrigerator. 4 Peanut butter packets and biscuits were stored in the third floor cabinets in which persons in care have access.
Corrective Action(s): Please ensure that all food is safely stored.
Date to be Corrected: March 18, 2023
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