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: In the servery area, Licensing observed Cleaning spray bottle located in the cabinet located under the sink. The cabinet door was unlocked and the doors to the room were left open. Licensing was informed although there are signs for staff to close the doors, that there are times, the doors remain open. The doors leading into the bath/spa room was also found to be open. Cleaning products are also located in the room.
Corrective Action(s): Please ensure cleaning chemicals are safely stored
Date to be Corrected: ongoing
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31850 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation: Meal menu is posted in the dining area, but snack menu is not available.
Corrective Action(s): Please ensure posting of the menu includes both the meal and snack
Date to be Corrected: March 23, 2021
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: 4 Staff files were reviewed, of which one was missing their immunization and TB information.
Corrective Action(s): Please ensure all staff file is complete
Date to be Corrected: March 23, 2021
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: Review of the Narcotic information indicates there were several occassions where double signature of 2 separate staff was missing. This is a requirement in the MSAC Policy and Procedure. Licensing was informed that there is a, system is in place to ensure that the counting of the medication is in place.
Corrective Action(s): Please ensure the MSAC Policy and Procedure is followed, which includes ensure both staff sign.
Date to be Corrected: ongoing
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: Use of restraint is used for one unit of the facility is in place without written medical agreement by the medical practitioner.
Corrective Action(s): Please ensure the medical practitioner has provided written agreement to the use of restraint
Date to be Corrected: March 31, 2021
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Evidence of that the some of the Policies have been reviewed at least once each year is available, but there are still come outstanding Policies that requires to be reviewed at least once a year.
Corrective Action(s): Please ensure Policies are reviewed at least once year
Date to be Corrected: April 5, 2021
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Based on the review of the selected care plan, evidence that yearly review and modification has not occurred. ADL information for one PIC has not been updated since 2019.
Corrective Action(s): Please ensure that care plan is up to date.
Date to be Corrected: March 31, 2021
|