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 (CORRECTED DURING INSPECTION): A temperature check of facility water accessible to persons in care found the temperature to be greater than 49° Celsius (temperatures of 54.9° C and 54.2° C were recorded).
Corrective Action(s): Ensure that water accessible to persons in care, from any source, is not heated to more than 49° Celsius.
Date to be Corrected: CORRECTED DURING INSPECTION
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: An inspection of the physical facility found that a wall near the servery was missing its wall board exposing the unfinished and damaged drywall behind which requires repair. Additionally, in one person in care's room there was a leak in the ceiling that caused water damage to the drywall (approximately 1 meter in length on the north side of the room) which requires repair.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: December 2, 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: A review of medications found that the effectiveness of a PRN medication for one person in care was not recorded which is contrary to policy.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: November 18, 2021
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: A review of the facility's emergency supplies found that there was insufficient food to sustain all persons in care and staff for three days in the event of an emergency.
Corrective Action(s): Ensure that an emergency plan sets out procedures to prepare for, mitigate, respond to and recover from any emergency including procedures for the evacuation of persons in care.
Date to be Corrected: December 16, 2021
CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: A review of person in care charts and care plans found no evidence that persons in care have been encouraged to be examined by a dental health care professional at least once every year.
Corrective Action(s): Ensure that persons in care are encouraged to be examined by a dental health care professional at least once every year.
Date to be Corrected: December 31, 2021
CARE AND/OR SUPERVISION: 34220 - RCR s.56(1) - A licensee must ensure that a person in care who leaves a community care facility for a temporary purpose has in his or her possession written documentation indicating the person in care's name, the community care facility's name and emergency contact information.
Observation (CORRECTED DURING INSPECTION): A review of care plans found no evidence that any persons in care had written documentation available to indicate the person in care's name, the community care facility's name, and emergency contact information to identify the person in care when the person in care leaves the facility for a temporary purpose.
Corrective Action(s): Ensure that each person in care has written documentation in their possession indicating the person in care's name, the community care facility's name, and emergency contact information to identify the person in care when the person in care leaves the facility for a temporary purpose.
Date to be Corrected: CORRECTED DURING INSPECTION
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 (CORRECTED DURING INSPECTION): A review of care plans for person in care found that one person in care's care plan called for the use of hip protectors and a fall mat; however, the person in care was found to have no hip protectors on and no fall mat in place.
Corrective Action(s): 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.
Date to be Corrected: CORRECTED DURING INSPECTION
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) 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: A review of the facility's menus found no evidence of at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide, for each day.
Corrective Action(s): 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.
Date to be Corrected: December 2, 2021
RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: A review of the facility's menus found no evidence that a record of menu substitutions was being kept.
Corrective Action(s): Ensure that a record of menu substitutions is kept.
Date to be Corrected: November 25, 2021
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: A review of facility menus found no evidence that menu audits had been completed.
Corrective Action(s): Ensure that a record is kept showing the results of food service and nutritional care monitoring (menu audits).
Date to be Corrected: November 25, 2021
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