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: A review of staff files found 2 of 7 staff performance evaluations were not completed.
Corrective Action(s): Please ensure that staff’s performance is regularly reviewed, as per the facility’s policy and procedure.
Date to be Corrected: April 10, 2020
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: The Licensee’s medication policies and procedures required that the medication refrigerator’s temperature was monitored twice daily. There was no record that this temperature was checked 2 times in February and 4 times in March 2020 in the main level medication room
Corrective Action(s): Please ensure that staff implement the policies and procedures of the MSAC.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34370 - RCR s.63(3)(c)(iv) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iv) reassessed by the person in care's medical practitioner, nurse practitioner or dietitian at least once every 30 days.
Observation: Review of 2 of 7 care plans found that there was no evidence that a medical practitioner, nurse practitioner, or dietitian had reassessed ongoing tray services received for 1 person in care for 2019 and 2020 and 1 resident’s file had no evidence of monthly reassessment for the October, November and December of 2019.
Corrective Action(s): Please ensure that a medical practitioner, nurse practitioner have, or dietitian has reassessed ongoing tray services at least every 30 days.
Date to be Corrected: April 10th, 2020
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: A review of 6 persons in care’s files was completed. As part of a person in care’s wound care plan, staff were to change a dressing every 3 days. Staff failed to implement this plan, as this person in care’s dressing was changed twice every 4 or 6 days and there after daily.
Corrective Action(s): Please ensure that care plans are implemented as required.
Date to be Corrected: April 10th, 2020
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: A comb and nail clipper, both with no identifiers, were observed in the tub room on the main floor.
Corrective Action(s): Please ensure that items intended for personal use (to ensure health and hygiene) are not available to others.
Date to be Corrected: April 10th, 2020
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: The fridge and freezer temperatures were not monitored and documented in 1 servery for 3 days and 2 days in the kitchen.
Corrective Action(s): Please ensure that all food is safely prepared, stored, served and handled.
Date to be Corrected: March 25, 2020
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