PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31750 - RCR s.35(1)(b) - A licensee must provide the following appropriately furnished and equipped areas: (b) safe and secure locations for medications and the records of persons in care.
Observation: Review of the physical facility noted that there were topical medications being stored in an unlocked closet in the hallway.
Corrective Action(s): Ensure all medications are stored in a secured location
Date to be Corrected: July 26 2021
STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Review of 6 staff files noted that 1 staff file did not contain a record of immunization status or TB status
Corrective Action(s): ensure all staff are in compliance with the provinces immunization and TB requirements
Date to be Corrected: July 26, 2021
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: Review of 6 staff files noted that 2 staff did not have recent performance evaluations. 1 was last completed in 2012 and 1 was last completed in 2018
Corrective Action(s): ensure performance reviews are completed and reviewed regularly
Date to be Corrected: July 26, 2021
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: It was noted during inspection that a medication cart was left unlocked and unattended in the dining room
Corrective Action(s): Ensure that all policies and procedures related to medication administration are implemented by employees
Date to be Corrected: July 26, 2021
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