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: Observed dining room tables edges worn. Room # 14 wall damage.
Corrective Action(s): To ensure all furniture, common areas are in good state of repair
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: Observed no temperature log present for medication fridge
Corrective Action(s): Fridge temperatures must be regulary checked/documented
Date to be Corrected: March 23, 2022
POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: MSAC /pharmacy inspection now due
Corrective Action(s): Ensure regular review/inpsection completed by pharmacy completed in a timely manner
Date to be Corrected: March 23, 2022
CARE AND/OR SUPERVISION: 34200 - RCR s.54(3)(b)(ii) - A licensee must (b) assist persons in care to (ii) obtain professional dental services as required.
Observation: No documentation present in 3 resident files reviewed in regards to assisting PICS yearly dental services
Corrective Action(s): Ensure documentation present indicating assistance provided to PICs for regular dental services
Date to be Corrected: March 23, 2022
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: Observed PIC personal items stored together in bin in tub room
Corrective Action(s): Ensure all personal items stored seperately
Date to be Corrected: March 23, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Observed juice containters in fridge not labelled, filled glasses of juice in fridge open/not labelled, food items in dining area cupboard not labelled/not sealed, open tea bags in cupboard.
Corrective Action(s): Ensure all food items are safely stored
Date to be Corrected: March 23, 2022
NUTRITION AND FOOD SERVICES: 37020 - RCR s.62(1)(b) - A licensee must ensure that a menu, made in accordance with this section, is developed (b) in any other case, for at least each 4 week period.
Observation: Only one menu present for the year
Corrective Action(s): Ensure seasonal menu present
Date to be Corrected: March 22, 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: No record of consent to in writing to call ambulance/medical practioner in case of accident
Corrective Action(s): Ensure all consent forms completed and present in PIC file
Date to be Corrected: March 22, 2022
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: No menu audits - last one present from Dec 2017
Corrective Action(s): Ensure all menu audits complete twice yearly
Date to be Corrected: March 22, 2022
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