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: Review of 21 PIC’s nutrition care plans found no evidence of nutrition and food audits being completed since 2019.
Corrective Action(s): 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.
Date to be Corrected: December 3, 2022
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 (CORRECTED DURING INSPECTION): The water temperature reading was taken in 2 different locations; the water temperature measured in the first washroom located in the East hallway was 57°C, the water measured in second washroom was 57.2°C.
Corrective Action(s): Ensure water accessible to a person in care, from any source, is not heated to more than 49°C.
Date to be Corrected: November 7, 2022
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: Inspection of the physical facility found the following:
1) East facing hallway near the exit had approximately 5-10 areas of chipped paint on the wall caused by walkers.
2) The south facing wall of the dining room has four large gouges in the drywall (two of which are approximately 30 cm in length, one is approximately 60 cm in length, and one is approximately 75 cm in length). This is a repeat contravention.
3) Along the entire length of the hallway on the east side of the building as well as on the doors at either end of the hallway had paint rubbed off in several areas of the door, including the front door to the facility.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: December 3, 2022
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): All purpose cleaner was found under the sink left unsecured in a PIC's washroom located in the East hallway.
Corrective Action(s): Ensure cleaning agents, chemical products and other hazardous materials are secure, safe and stored.
Date to be Corrected: December 3, 2022
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: Review of the facility's emergency supplies found food rations that had expired in June 2022 and emergency drinking water that had expired in February 2020.
Corrective Action(s): Ensure that emergency supplies are checked regularly for expiration dates.
Date to be Corrected: December 3, 2022
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: Review 1 of 12 PIC's health care records indicated that a self-medication administration plan was in place. The form indicated that the next reassessment would take place on May 4, 2022, there was no evidence to suggest this reassessment had occurred.
Corrective Action(s): Ensure that the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Date to be Corrected: December 3, 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: Review of 3 of 12 PIC's health care records found no evidence of immunization records.
Corrective Action(s): Ensure all persons admitted to community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: December 3, 2022
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 (CORRECTED DURING INSPECTION): Review of their medication cart found two PRN medications with an expiry date of October 2022.
Corrective Action(s): Ensure expired medications are returned to the pharmacy.
Date to be Corrected: December 3, 2022
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Review of 1 of 12 PIC's health care records did not have consent to receive medical treatment.
Corrective Action(s): Ensure that consent in writing from the person in care (PIC) or parent or representative of the PIC to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Date to be Corrected: December 3, 2022
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(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: Review of 1 of 21 PIC's weight charts determined that one weight was not captured for the month of September 2022 and there was no documentation provided to explain why the weight was missing.
Corrective Action(s): Ensure that each person in care is weighed at least once a month or provide a reason as to why the weight could not be obtained.
Date to be Corrected: December 3, 2022
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