PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation (CORRECTED DURING INSPECTION): In one servery area, within an unlocked cupboard accessible by persons in care, there were a pair of scissors and person in care's electric shaver found. There was also an unlocked drawer that is usually to be kept locked, as per staff.
In another servery, a cupboard which keeps cleaning chemicals had a broken lock, making the contents accessible to persons in care. In one medication area within the resident lounge, there was an unlocked cupboard with three pairs of scissors, a sewing kit with needles and a plastic box with packaged syringes inside.
Corrective Action(s): Ensure all cleaning agents, and other hazardous materials are kept secure and safe, and inaccessable to persons in care.
Date to be Corrected: February 28, 2022
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 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Eight staff files were reviewed and three of the staff files did not have evidence of a performance appraisal within the facility's policy timelines.
Corrective Action(s): Ensure all staff's performance are assessed on a regular basis.
Date to be Corrected: March 16, 2022
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation (CORRECTED DURING INSPECTION): Six person in care's charts were reviewed and there was no evidence of current restraint agreements from their medical practitioner in two person in care's charts.
Corrective Action(s): Ensure all persons in care who require a restraint have a written agreement to use the restraint from the medical practitioner or nurse practitioner.
Date to be Corrected: February 28, 2022
CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: Six person in care's charts were reviewed and in five of the six charts, there was no evidence of the licensee having encouraged the person in care to be examined by a dental health care professional on an annual basis, at least.
Corrective Action(s): Ensure all persons in care are encouraged to be examined, at least annually, by a dental health care professional.
Date to be Corrected: March 16, 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 (CORRECTED DURING INSPECTION): After a review of six person in care charts, two person in care's charts had incomplete immunization screening forms present.
Corrective Action(s): Ensure all persons in care have completed screening forms as part of the Province's immunization and tuberculosis control programs.
Date to be Corrected: February 28, 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 (CORRECTED DURING INSPECTION): In each servery throughout the facility, there were containers of food that were not the original packaging, with no label attached.
Corrective Action(s): Ensure all food items which are removed from their original packaging are labelled appropriately.
Date to be Corrected: February 28, 2022
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