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 7 staff files noted that 3 staff did not have performance evaluations on file and 1 staff who had worked since 2019 only had a probationary evaluation
Corrective Action(s): Ensure all staff have regular performance evaluations
Date to be Corrected: Sept 30, 2021
STAFFING: 32250 - RCR s.44(1)(a) - A licensee must ensure that employees responsible for the preparation and delivery of food (a) have the experience, competence and training necessary to ensure that food is safely prepared and handled and meets the nutrition needs of the persons in care.
Observation: Review of staff files noted that 3 staff did not have food safe certification on record
Corrective Action(s): Ensure all staff responsible for food prep and delivery have the appropriate training
Date to be Corrected: Sept 30, 2021
CARE AND/OR SUPERVISION: 34680 - RCR s.81(3)(e)(ii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (ii) a plan for preventing the person in care from falling.
Observation: 1 ADL sheet in a PIC's room showed that the PIC is a falls risk but no interventions for falls were not noted on the ADL sheet
Corrective Action(s): Ensure that all PIC's who are falls risk have falls prevention plans available to staff
Date to be Corrected: Sept 30, 2021
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: 2 of 4 care plans reviewed noted that the last review or revision date was from 2019
Corrective Action(s): Ensure all care plans are reviewed yearly
Date to be Corrected: Sept 30, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: Review of 7 staff files found that 1 staff was missing both TB and Immunization records
Corrective Action(s): Ensure all persons employed have a record of their TB and immunization status
Date to be Corrected: Sept 30, 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: 1 of 4 PIC's care plans reviewed found that there was no record of TB or immunization status
Corrective Action(s): Ensure all persons admitted to the facility have a record of their TB and Immunization status
Date to be Corrected: Sept 30, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation:
* 5 days out of 16 fridge and freezer temperatures were not documented in cedar house servery
* Unlabeled food items in the fridge in cypress servery
* Pudding left out open on the medication cart while not being used
Corrective Action(s): Ensure that all food is safely stored and documentation is completed
Date to be Corrected: Sept 30, 2021
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: 2 topical medications that were expired were still in the PIC's medication storage area
Corrective Action(s): Ensure expired medications are returned to the pharmacy
Date to be Corrected: corrected at time of inspection
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