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: In one PIC's bathroom, mold was noted in the grout of the shower tiles. In another bathroom, a patch of rust was noted in the corner of the tub. Broken pieces of cement were observed in the back pathway of the house.
Corrective Action(s): Please ensure that the facility is maintained in a safe and clean condtion.
Date to be Corrected:
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: A review of the MAR indicated that one PIC's prn medication which was signed but the effect of the medication was not noted. The facility medication administration policy states that whenever a prn medication is used, the reason and outcome of the medication needs to be recorded on the back of the MAR. It was noted that the last visit from the pharmacist was in March 2018. The medication administration policy states that the pharmacist must attend the facility annually. This is a repeat contravention.
Corrective Action(s): Please ensure that the policies and procedures of the MSAC committee are followed.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34600 - RCR s.81(3)(a)(i) - A care plan must include all of the following: (a) a plan to address (i) medication, including self-administered medication if approved under section 70 (4) [administration of medication].
Observation: One PIC is provided with medications which may not be consumed until 2 hours later, as per PIC's preference. While staff state that supervision is provided, there is potential risk for this PIC and other PICs. Staff stated there is no care plan for this practice.
Corrective Action(s): Please ensure there is a care plan to address this practice.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: One PIC had dental work completed in April 2019. The PIC's oral care plan was last reviewed in April 2017. An update to the oral care plan was not completed.
Corrective Action(s): Please ensure that care plans are updated when there is a substantial change in condition.
Date to be Corrected:
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: A review of one PIC's care plans indicated that the PIC did not have a nutrition, oral, and health care plan reviewed since 2017. A RD screening form was also not completed since 2017.
Corrective Action(s): Please ensure that care plans and RD screening forms are completed on a yearly basis.
Date to be Corrected:
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): Licensing observed food stored on the floor of the food storage area. One freezer's temperature was noted to be too warm at -15 Celsius.
Corrective Action(s): Please ensure that all food is stored off the floor as per food safe requirements. Please ensure that temperature log records are monitored to ensure proper temperatures are being maintained.
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: The menu substitution record was reviewed and it was noted that on two occasions the same food group was not substituted for the menu item. In another entry, it could not be confirmed if the substitution was made from the same food group as the details of the menu item could not be verified.
Corrective Action(s): Please ensure that staff are provided education with respect to the different food groups in Canada's Food Guide. A discussion was held regarding having recipes available for staff to ensure consistency in food products being prepared.
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37100 - RCR s.62(3) - The licensee must take all reasonable steps to ensure that the food served to persons in care follows the menu and, if unable to do so because of unforeseen circumstances, that the food provided to persons in care meets the nutritional requirements set out in subsection (2).
Observation: Licensing observed that there was no evidence of any of the evening's main entree in either the fridge or freezer. Staff confirmed that meats are usually not thawed the day before.
Corrective Action(s): Please ensure that procurement of groceries matches the meals to be provided as indicated on the menu. Meats should be thawed in the fridge as per foodsafety guidelines.
Date to be Corrected:
RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: For a newly admitted PIC, information on immunizations could not be located by the staff member.
Corrective Action(s): Please obtain immunization status for this PIC.
Date to be Corrected:
RECORDS AND REPORTING: 39310 - RCR s.81(1) - If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: Licensing observed that there was no care plan for one PIC who was admitted in 7 months ago.
Corrective Action(s): Please ensure that all admissions have a care plan within 30 days of admission. For this PIC please ensure that a care plan is developed and includes all of the required types of care plans.
Date to be Corrected:
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