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: Three tables in the dining room were observed to have their finish almost entirely worn off their tops with two table tops exposing the bare wood underneath.
Corrective Action(s): Ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair.
Date to be Corrected: November 29, 2021
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 found the following:
1) The finish on the kitchen cupboards near the dishwasher has worn off making it hard to keep clean.
2) The south wall of the dining room has four large gouges in the drywall (two of which are approximately 30 cm in length, one is approximately 60 cm in length, and one is approximately 75 cm in length) which require repair and painting.
3) A gutter on the north side of the facility is bent down resulting in water dripping out which requires repair.
4) A shower curtain in a bathroom on the east side of the facility was observed to be torn and hanging down which requires replacement (CORRECTED DURING INSPECTION)
5) Along the entire length of the hallway on the east side of the building as well as on the doors at either end of the hallway the paint has rubbed off and requires repainting.
6) The laundry room floor was observed to have a soft spot which should be assessed to determine if it requires repair.
Corrective Action(s): Ensure that all rooms and common areas are in a good state of repair.
Date to be Corrected: December 15, 2021
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: An inspection of the physical facility found that a bathroom on the east side of the facility had a dirty floor with garbage on it from an overflowing garbage can (CORRECTED DURING INSPECTION). In another bathroom on the east side of the facility (near the vanity on the floor), a metal heat register cover that did not fit properly was observed to be sticking up (approximately 1 cm) posing a potential tripping hazard. Additionally, an exhaust fan in an ensuite bathroom of a person in care was found to be covered in dust and requires cleaning to ensure proper ventilation.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: November 29, 2021
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 (CORRECTED DURING INSPECTION): An inspection of the physical facility found that a storage area used to store cleaning agents and other hazardous materials was left unlocked.
Corrective Action(s): Ensure that cleaning agents, chemical products, and other hazardous materials are securely and safely stored.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31880 - RCR s.69(3)(b)(ii) - A licensee must ensure that (b) in the case of a person in care whose short term care plan or care plan provides for the person in care to self-administer medication, the person in care (ii) stores all medications in the storage area described in subparagraph (i).
Observation (CORRECTED DURING INSPECTION): The medication of a person in care who self-administers was found to be stored in an unlocked backpack in the person in care's room. Going forward, the medication will now be stored in a locked drawer in the person in care's room.
Corrective Action(s): Ensure that medication for self-administration is stored in a safe and secure area.
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: A review of staff files found that two staff files did not have evidence of immunization records.
Corrective Action(s): Ensure that persons employed in a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: November 22, 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 (CORRECTED DURING INSPECTION): 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:
CARE AND/OR SUPERVISION: 34080 - RCR s.49(3) - A licensee must assess each person in care on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.
Observation: A review of admission records found that for two persons in care there was no record available that showed that an assessment had been completed to determine the risk that they may leave the community care facility without notification of an employee.
Corrective Action(s): Ensure that persons in care on admission are assessed to determine the risk that they may leave the community care facility without notification of an employee.
Date to be Corrected: November 22, 2021
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: A review of person in care admission records found that one person in care had an incomplete tuberculosis screening.
Corrective Action(s): Ensure that all persons in care admitted to the community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: November 29, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation (CORRECTED DURING INSPECTION): An inspection of the facility's kitchen and food storage areas found five bins used to store dry food that were not dated and one bin of dry food that had neither a date nor a label indicating what was stored in the bin. It was also observed in a food storage cupboard in the facility's basement that three food items were past their best before date (one of which was best before 26JUL2021). Additionally, it was observed that two items in the kitchen fridge were neither dated nor labelled.
Corrective Action(s): Ensure that all food is safely prepared, stored, served and handled.
Date to be Corrected:
MEDICATION: 36130 - RCR s.70(4)(a) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (a) approved by the medication safety and advisory committee and the medical practitioner or nurse practitioner who prescribed or ordered the medication.
Observation: A review of care plans found no evidence that the plan to self-administer medication for one person in care had been approved by the medication safety and advisory committee and the medical practitioner or nurse practitioner who prescribed or ordered the medication.
Corrective Action(s): Ensure that, prior to permitting a person in care to self-administer medications, the plan for self-administration is approved by the medication safety and advisory committee and the medical practitioner or nurse practitioner who prescribed or ordered the medication.
Date to be Corrected: November 15, 2021
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: A review of care plans for persons in care found no evidence of written consents to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Corrective Action(s): Ensure that consent in writing is kept with each person in care's record from each person in care or a parent or a representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Date to be Corrected: November 22, 2021
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