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: A test of 2 water sources showed that the kitchen water temperature was 51.4 and the bathroom temperature was 49.1
Corrective Action(s): please ensure all water sources are not heated to more than 49 degrees Celsius
Date to be Corrected: April 10, 2019
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: during inspection it was noted that employee performance reviews were not available for review
Corrective Action(s): ensure performance reviews are completed on a yearly basis as per facility policy and are available for review
Date to be Corrected: April 24, 2019
POLICIES AND PROCEDURES: 33130 - RCR s.68(3)(a) - The medication safety and advisory committee must establish and review as required (a) training and orientation programs for employees who store, handle or administer medications to persons in care.
Observation: The MSAC does not review the training and orientation program for employees
Corrective Action(s): Please ensure the MSAC reviews the training program and it is noted on the meeting minutes
Date to be Corrected: Next MSAC meeting
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 3 PIC's MARs showed that on 4 separate PRN administrations no result was noted on the nurses notes
Corrective Action(s): Please ensure that all documentation is completed as per the MSAC and facility policy in regards to PRN documentation
Date to be Corrected: April 24, 2019
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: In the tub room it was noted that each person did not have a none slip mat available for the tub
Corrective Action(s): Please unsure all persons have their own tub mat available
Date to be Corrected: April 10, 2019
NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Upon review of the menus, there was a 4 week rotational menu available and appeared to provide the required 3 meals per day as per the Canada food guide however there were no menu audits completed to ensure the menus meet the requirements
Corrective Action(s): Complete the meals and more audits to ensure that menus are meeting all required standards
Date to be Corrected: April 10, 2019
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: It was noted that dead files and personal information binders were not stored in a secure area.
Corrective Action(s): ensure all personal records and information are stored in a secure area
Date to be Corrected: April 10, 2019
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