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: It was observed that menu audits had been completed for 1 of 4 fall/winter menus and 0 of 4 spring/summer menus.
Corrective Action(s): In order to ensure, as per RCR s. 66(1) "A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan", ensure that all food weeks are monitored.
Date to be Corrected: April 9, 2021
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: Upon inspection of rooms and common areas, Licensing observed the following:
- Rubber floor molding on the side of the hearth was missing, exposing sharp tile edges.
- Rubber baseboard molding is peeling away from poles in kitchen area.
- Surfaces of walls and corners have wheelchair scuff marks in the hallways and on the sides of poles at the entrance to the kitchen area.
- The washroom wall behind the toilet in the tub room has a large, rectangular hole approximately 4 inches by 2 inches that exposes drywall.
- The floor tiles in the toilet area of the washroom are not sealed around the perimeter and gaps exist between the tiles and the walls and the tiles and the cabinet.
- The wall in one PICs bedroom has a large, circular dent in the drywall with a diameter of approximately 6 inches, exposing drywall.
- The chest freezer had a heavy build-up of frost approximately 1 to 1.5 cm thick on the upper section of the sides. A build-up of food crumbs was observed on the interior bottom section of the freezer.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: April 9, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31580 - RCR s.30(a) - A licensee must ensure that all bathrooms have (a) a door, equipped with a lock that can be opened from the outside in the case of an emergency.
Observation: The pocket door of the main washroom is not equipped with a functioning lock.
Corrective Action(s): Ensure that the bathroom doors can lock and be unlocked from the outside.
Date to be Corrected: April 9, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: Topical medication for two PICs were stored together.
Corrective Action(s): Corrected at time of inspection.
Date to be Corrected: Corrected at time of inspection.
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 sample of 4 employee files were reviewed. 2 employee performance appraisals were completed 27 months ago and 13 months ago.
Corrective Action(s): Ensure that employee performance appraisals are completed annually, as per facility policy.
Date to be Corrected: April 9, 2021
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: During day one of the routine inspection, fire extinguishers and emergency lighting were last inspected July 2019. By day 2 of the inspection, it was observed that an inspection of 2 fire extinguishers and emergency lights had been completed. One emergency light in the hall outside 4 PIC bedrooms requires and new battery and was not functioning at time of inspection.
Corrective Action(s): Ensure emergency equipment and supplies are maintained in order to respond to an emergency.
Date to be Corrected: March 30, 2021
POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: Management informed Licensing that the pharmacist has not attended the facility since April 2019 to inspect the handling, administration, and storage of medication, as is required annually. It was observed that the Medication Administration policy included a procedure guiding staff around making handwritten changes to the directions for the use of a medication, which is in contravention to RCR s.71(a) "A licensee must ensure that (a) employees do not make handwritten changes to the directions for use of medication on the medication container or package".
Corrective Action(s): Ensure the pharmacist attends the facility as required to review procedures related to the safe handling, storage, and administration of medications and that the Medication Administration policy meets legislative requirements.
Date to be Corrected: April 9, 2021
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: 2 of 2 PIC files reviewed did not include a record of immunization or compliance with the Province's tuberculosis control program.
Corrective Action(s): Ensure person in care records include on admission a record of immunization and compliance with the Province's tuberculosis control program.
Date to be Corrected: April 9, 2021
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: PIC hygiene products and shower sponges were stored together in the shower area and could not be identified according to PIC.
Corrective Action(s): Ensure personal hygiene products are stored in a manner that clearly identifies the PIC.
Date to be Corrected: March 30, 2021
MEDICATION: 36150 - RCR s.71(a) - A licensee must ensure that (a) employees do not make handwritten changes to the directions for use of a medication on the medication container or package
Observation: Handwritten changes were observed on a PICs medication administration record (MAR).
Corrective Action(s): Ensure pharmacy packages all medications and provides directions for use of a medication.
Date to be Corrected: March 30, 2021
MEDICATION: 36160 - RCR s.72(a) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (a) the person in care is no longer taking the medication.
Observation: One discontinued PRN medication stored was with current medications.
Corrective Action(s): Ensure discontinued medications are returned to the pharmacy.
Date to be Corrected: Corrected at time of inspection.
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: One expired topical medication stored with current medications.
Corrective Action(s): Ensure expired medications are returned to the pharmacist.
Date to be Corrected: Corrected at time of inspection.
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (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: 3 out of 5 PIC files were reviewed and it was observed that the weight of 1 PIC had not been recorded in 2021 and a second PIC had 2 weights missing for 2020.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: April 9, 2021
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