LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: A random review of persons in care charts indicated an assessment document was not completed (Specifics were provided during the inspection).
A review of the nutrition audits did not indicate an action plan when the audit was not 100%. For example, nutrition care plan audit completed in February 2018 with a score of 92% (will be redone this month and is to be done every 6 months when 100% is not achieved); Dining room audit completed May 22, 2018 noted with no action plan; weight audit completed in June 2018 with 80% score. There was transitioning in the position that completes these audits. The current audits completed by the staff person appear to include an action plan where required when 100% is not achieved. Please ensure all nutrition audits are thoroughly completed and they are being completed according to the nutrition audit schedule.
Corrective Action(s): Please ensure care and services are regularly monitored to ensure the requirements of the Residential Care Regulation and Community Care & Assisted Living Act are being met.
Date to be Corrected: Please provide a written response to these items by the timeline noted in this report.
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: The hot water temperature was measured in both buildings at the ensuite washroom sinks. Temperatures were 52.8 degrees Celsius; 51.2 degrees Celsius; 51.8 degrees Celsius; 49.5 degrees Celsius and 48.4 degrees Celsius in the ensuite washroom sinks measured (Room numbers provided at the time of inspection). The Manager put in a requisition with Maintenance to ensure the hot water temperature at all water sources accessible to persons in care is not heated to more than 49 degrees Celsius.
Corrective Action(s): Please provide a written response to this item as soon as possible as noted in this inspection report.
Date to be Corrected: Please ensure the hot water temperature at all water sources accessible to persons in care is not heated to more than 49 degrees Celsius.
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 random review of the medication administration records in the medication room was noted over to be thoroughly completed with the results/effectiveness of PRN medication (as needed), however some were not noted with the results/effects (Specifics provided during the inspection).
Corrective Action(s): Please ensure all staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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