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): Water temperatures taken in three person in care rooms, all exceeded 49 degrees C, highest being 51.6 degrees C
Corrective Action(s): Licensee must monitor water temperatures regularly throughout facility to ensure they do not exceed 49 degrees
Date to be Corrected:
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: The following was observed throughout the facility: -One peeling table top, in common area -Commode in person in care's room had duct tape on arms of it (both arms), making it difficult to clean -Fall mats in two person in care rooms noted to be in poor repair/ripped with exposed foam, which were possible tripping hazards, and also making it difficult to clean -One lift in hallway noted to have a broken brake (this was removed from service on day one of inspection) -Vinyl of Chairs in large dining room had cracks in bottom cushion (several chairs) and were dirty with food drips
Corrective Action(s): Licensee must monitor for and make plans to repair items within the physical facility to a state of good repair
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Throughout the facility, the following was observed:
-Tripping hazard noted in two areas, including carpet transition strip broken, and long cord coming from the wall, into main part of room where people walk
-Exposed electrical wires noted in an approximately baseball sized hole in ceiling, which had fibers exposed. There was also a second separate hole in ceiling also with fibers exposed, which could fall to areas where persons in care are present, in the hallway
-Two Covers for skylights in the hallway noted to have debris resting on top of them. Additionally, one was also in poor repair/cracked in a corner and broken which is difficult to be cleaned and potentially could break further
-Carpet stained in many areas, in common area of TV room. It was described that the room had recently been used as an additional dining area due to Covid requirements. Informed there is a plan in place to clean carpets.
-Two spa rooms inspected, garbage was overflowing with used incontinence products and a strong odor noted in both rooms
-Baseboard heater covers noted to be loose in several areas of building, which could be a potential hazard to persons in care due to sharp materials exposed
-The handle on spa tub missing the handle/cover and rusty, making it difficult to clean
-Emergency signage half removed on one exterior door,and not clearly visible behind window tint on multiple exterior doors
-Multiple person in care's rooms noted to have blinds in poor repair, with broken or missing slats
-One person in care room was missing blinds completely, which is a concern for the protection of the privacy of the occupant
Corrective Action(s): Licensee must monitor for and make plans to repair all rooms and common areas within the physical facility to a state of clean and safe condition
Date to be Corrected:
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: The following was observed in several areas of the facility:
-Cabinets in common area unlocked with chemicals present, easily accessible by persons in care
-Cabinet in designated work area (servery cupboard) with chemicals present, not locked, easily accessible by persons in care
-Unlabelled basket with unlabelled razor present in Spa tub room, of concern is cross contamination as multiple persons use the room
Corrective Action(s): Licensee to ensure all chemicals and hazardous materials are safely stored and inaccessible to persons in care.
Date to be Corrected:
STAFFING: 32010 - RCR s.37(1)(a) - 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) a criminal record check for the person.
Observation: On review of seven staff files, it was noted two staff did not have current criminal record checks on file. One of the two staff doing orientation/working are currently working without a valid criminal record check. One of the two staff persons started their orientation prior to the facility having received the criminal record check for that person.
Corrective Action(s): Licensee must not employ a person in community care facility unless the manager has obtained a criminal record check for that person prior to them starting working.
Date to be Corrected:
STAFFING: 32020 - RCR s.37(1)(b) - 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: (b) character references in respect of the person.
Observation: On review of seven staff files, it was noted five staff files did not have two references on file. It was explained that two staff were hired before changes in contract services and references may have been lost during transition.
Corrective Action(s): Please ensure a minimum of two character references are obtained for each person hired to work in the community care facility.
Date to be Corrected:
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: During review of seven staff files, in three staff files, immunization records were missing or incomplete
Corrective Action(s): Please ensure the manager has obtained evidence that the person hired has complied with the Province's immunization and TB control programs.
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: It was observed that ADLs in person in care's rooms did not contain specific information from the care plan to guide staff in providing care to persons in care. For example:
-diet textures were not reflected on ADL sheets
-for three persons in care, their fall risk/fall care plan was not indicated on the ADL sheet
-One person in care's care plan, ADLs and Kardex had not been updated to reflect mobility status change
-One person in care's information on Kardex was inconsistent with ADL and Care plan to provide guidance on care related to behavior
Corrective Action(s): The licensee must ensure that the care and supervision of persons in care is consistent with the 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: On review of five persons in care charts, it was observed that:
-Two of five person in care charts did not have a completed TB Screening form present
-Three of five persons in care charts did not have completed childhood immunization form present
Corrective Action(s): Licensee to ensure forms are completed as per the provincial immunization and TB program, in their entirety.
Date to be Corrected:
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: On review of medication rooms, it was noted two medications from contingency stock did not have pharmacy labels affixed. Staff informed CCFL that they didn't know why the medications didn't have labels attached.
Corrective Action(s): Please ensure all medications have been packaged by the pharmacist.
Date to be Corrected:
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: Review of Internal Incident Reports system, it was noted 3 internal incident reports that meet definition of Reportable Incident were not reported to CCFL.
Corrective Action(s): The licensee must immediately notify a medical health officer/licensing officer in the form and manner required by the medical health officer, if a person in care is involved in a reportable incident. Please submit a written plan, including a timeline, of how incidents that occurred within the previous twelve months, dating back to June 2020, will be reported to licensing.
Date to be Corrected:
RECORDS AND REPORTING: 39670 - RCR s.93 - A licensee must, to the greatest extent possible while maintaining the health, safety and dignity of persons in care, keep the records and personal information of persons in care confidential.
Observation: During routine, it was noted the Nurses computer screen was open, with person in care's information visible, on medication cart. Nurse was not present at the cart, and cart was in a high traffic area with many persons walking past. Licensee informed CCFL that their usual main screen with a privacy shield was not currently working and was in process to be fixed, and the laptop being used on this day was a temporary fix.
Corrective Action(s): Please ensure, to the greatest extent possible, all persons in care personal records and personal information are kept confidential.
Date to be Corrected:
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