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: It was noted that in 3 of the washrooms the mirror shelves were worn down to the raw wood and therefore can not be cleaned appropriately
Corrective Action(s): please ensure that all rooms and common areas are maintained in a state of good repair
Date to be Corrected: June 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: Review of 6 staff files found that 1 staff was missing the TB and Immunization records
Corrective Action(s): Ensure all staff employed have evidence on file that they meet the provinces immunization and TB requirements
Date to be Corrected: June 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: The policy manual has had a number of policies reviewed in the last year however there is no documentation that the whole policy manual has been reviewed
Corrective Action(s): Ensure that the policy manual is reviewed and if needed updated yearly
Date to be Corrected: March 30, 2021
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Review of the contingency medication found that 1 medication had been administered but had not been signed off for on the actual medication card, medication was however signed off for on the MAR
Corrective Action(s): Ensure staff are following the medication administration policies
Date to be Corrected: March 23, 2021
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: Review of the medication storage area noted 2 medications were expired
Corrective Action(s): Ensure all expired medications are returned to the pharmacy
Date to be Corrected: Corrected at time of inspection
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