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: The dining room wall located on the East wing had a paint chip measuring approximately 2-3 inches in length caused by dining room chairs.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: June 11, 2022
STAFFING: 32270 - RCR s.44(2) - A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is (a) a nutrition manager with membership in the Canadian Society of Nutrition Management, (b) a person who is eligible to be a member of the Canadian Society of Nutrition Management, or (c) a dietitian.
Observation: Review of staff files determined the staff supervising the preparation and delivery of food does not have membership with the Canadian Society of Nutrition Management.
Corrective Action(s): A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is (a) a nutrition manager with membership in the Canadian Society of Nutrition Management, (b) a person who is eligible to be a member of the Canadian Society of Nutrition Management, or (c) a dietitian.
Date to be Corrected: June 11, 2022
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: A review of the narcotic drug count had inconsistencies whereby, the second nurse signature was not was documented as per facility 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: June 11, 2022
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 2 of 10 persons in care admission records found the following:
- Incomplete immunization and tuberculosis screening records.
- No evidence of immunization status or tuberculosis records. This is a repeat contravention.
Corrective Action(s): Ensure that all persons in care comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: June 11, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: An inspection of the kitchen found the following:
- The refrigerator and freezer located in the main kitchen found that temperatures were recorded once daily and not twice daily as required.
- Ice cream was found in the freezer located on the North wing without any dates or labels.
Corrective Action(s): Ensure that all food is safely prepared, stored, served and handled.
Date to be Corrected: June 11, 2022
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of 2 of 10 PIC's weight charts determined that weights have not been captured for the month of April and there was no documentation provided to explain why the weight was missing.
Corrective Action(s): Ensure that each person in care is weighed at least once a month or provide a reason as to why the weight could not be obtained.
Date to be Corrected: June 11, 2022
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