PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31070 - RCR s.16(2)(a) - A licensee must ensure that each bedroom, bathroom and common room is lit sufficiently to (a) permit a person to carry out effectively the types of activities that would be reasonably expected in the ordinary use of the room.
Observation: Lighting in the downstairs hallway and staff room is dim and is difficult to see properly in
Corrective Action(s): Ensure all rooms are sufficiently lit
Date to be Corrected: April 30, 2019
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: During inspection of the facility it was noted that
* An armchair in the activity room has very worn arms
* 3 PIC's beds need replacing as they are getting worn and springs can be felt
* Baseboard heater in the shower room is rusty
Corrective Action(s): Ensure all furniture and equipment is maintained in a good state of repair
Date to be Corrected: April 30, 2019
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: It was noted during inspection of the physical facility that:
*The kitchen cupboard doors are worn down to the wood on the edges and are unable to be sanitized appropriately the kick boards under the cupboard have worn and damaged paint and the rubber trim is peeling off
* The dining area roof has a large stain from a previous water leak
* a cover over the mechanical part of an automatic door is missing and the wires are exposed
* The light cover in the storage room is missing
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: April 30, 2019
STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person.
Observation: Upon review of the staff files 4 of 6 had expired criminal record checks
Corrective Action(s): The licensee must ensure that all employees have a current criminal record check on file
Date to be Corrected: March 1, 2019
STAFFING: 32020 - RCR s.37(1)(b) - 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: (b) character references in respect of the person.
Observation: Review of the staff files noted that 3 of 6 did not have references
Corrective Action(s): Ensure that character references are obtained for all employees
Date to be Corrected: March 1, 2019
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 staff files determined that 4 of 6 staff did not have documentation of TB status and 2 of 6 did not have documentation of immunization
Corrective Action(s): ensure all employees comply with the provinces immunization and tuberculosis programs
Date to be Corrected: March 1, 2019
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Last review of policy manual was completed in October 2017. Manager explained that they are currently in the process of updating the polices
Corrective Action(s): ensure that the policies and procdures are reviewed annually
Date to be Corrected: April 30, 2019
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: Upon review of the Medication Administration record it was noted that:
* There were 3 PRN's administered but no documentation was recorded in the nursing notes.
* Hand written MAR labels were used
* Notes to staff were written on the MAR sheets
Corrective Action(s): Ensure all PRN's are documented as per the medication administration policy, labels are printed by the pharmacy, and notes to staff are not recorded on the MAR
Date to be Corrected: February 14,2018
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 9 PIC's files noted that 8 of 9 files had no immunization records and 6 of 9 had no TB records
Corrective Action(s): Ensure all PIC's admitted to the facility comply with the provinces Immunization and Tuberculosis programs
Date to be Corrected: March 1, 2019
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: review of hygiene practices noted that:
*nail clippers were stored together and unlabeled
*personal shower items stored in a shared bathroom were not labeled
Corrective Action(s): ensure all personal hygiene items are labeled with the PIC's name and stored separately
Date to be Corrected: February 8, 2019
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: The freezers on the lower floor
* packages of chicken and fish need expiry dates and labels
* Freezers are very full and some items were not frozen completely
Corrective Action(s): Ensure that all food is stored safely
Date to be Corrected: February 7, 2018
RECORDS AND REPORTING: 39630 - RCR s.91(3) - A licensee must ensure that a record relating to a person in care is accessible only to employees who require access to perform their duties in relation to the person in care.
Observation: Old PIC files and dead files are stored in an unsecured closet in an area that is accessible to PIC's and public
Corrective Action(s): ensure all files and personal information is stored in a secured area and is only accessible to employees
Date to be Corrected: Feb 15, 2019
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