PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: Clipper storage organizer in two spa rooms has its base chipped and rust observed.
Corrective Action(s): Please ensure that all furniture and equipment for use by persons in care are maintained in a safe and clean condition.
Date to be Corrected: December 31, 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: Persons in care room doors and door frames have scratches, scuff and chips. PIC's rubber door protector were ripped. Evidence of water leak seen below the sink and countertop edge was detached in second floor servery. Tea room's countertop edge measures 4x2 inches was removed. Wood hand rails were chipped, exposing rough edges and a risk for splinters observed in first and second floor units. A baseboard in PIC's door was chipped. Evidence of waterleak under the sink and baseboard was detached in first floor dining area.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: January 30, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Coffee stains on cabinet doors & drawers beneath the coffee machine in first and second floor servery. Drawers in all spa rooms requires cleaning.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: December 31, 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: A bottle of disinfectant cleaning solution and a bottle of clog destroyer solution were stored in the unlocked cabinet in second floor spa room. A bottle of disinfectant cleaning solution was seen on top of the side table and sink countertop in first floor spa room.
Corrective Action(s): Please ensure to have a secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous material.
Date to be Corrected: December 31, 2022
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: One of 11 staff files has no valid first aid and CPR certificate on file
Corrective Action(s): Please ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate.
Date to be Corrected: December 31, 2022
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: The insulin medication found in medication cart has no date when it was opened, this medication can be stored outside of the fridge for 28 days. Medication refrigerator temperature was not recorded 20 times in December 2022, temperature has to be monitored twice daily. Narcotic count sheet missing 5 second signatures. Swab specimen was found in the medication fridge dated November 29, 2022.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: December 31, 2022
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: A kitchen freezer temperature was not recorded 11 times in November and December 2022. A servery refrigerator temperature was not recorded 2 times in December 2022. A drawer in the activity area containing cutleries was left unlocked, as per staff it should be locked after each use.
Corrective Action(s): Please ensure that policies are implemented by employees.
Date to be Corrected: December 31, 2022
CARE AND/OR SUPERVISION: 34370 - RCR s.63(3)(c)(iv) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iv) reassessed by the person in care's medical practitioner, nurse practitioner or dietitian at least once every 30 days.
Observation: Two persons in care provided with ongoing room tray service has no reassessment every 30 days on file.
Corrective Action(s): Please ensure that meals are provided by on going tray service reassessed by the person in care's medical practitioner, nurse practitioner or dietitian at least once every 30 days.
Date to be Corrected: December 31, 2022
CARE AND/OR SUPERVISION: 34470 - RCR s.73(2)(c) - In addition to the requirements under subsection 73(1), the following conditions apply to the use of a restraint under section 74(1)(b) [when restraints may be used]: (c) the use of the restraint, its type and the duration for which it is used must be documented in the care plan of the person in care.
Observation: One PIC with consent to use the restraint was not documented in the PIC's care plan.
Corrective Action(s): Please ensure that the following conditions apply to the use of a restraint, the use of the restraint, its type and the duration for which it is used must be documented in the care plan of the person in care.
Date to be Corrected: December 31, 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: Four of 10 persons in care has no evidence of compliance with the Province's immunization and tuberculosis control program.
Corrective Action(s): Please ensure that all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control program.
Date to be Corrected: January 30, 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: Unlabelled PIC's nail clippers stored inside the drawer in spa room. PICs personal items stored inside the cabinet in two spa rooms. Used PIC's hair brush and PIC's sling were seen on top of the cart in north spa room. PIC's toothbrush and toothpaste were placed directly on top of the PIC's sink countertop.
Corrective Action(s): Please provide a plan as to how you are going to ensure to assist persons in care maintaining health and hygiene.
Date to be Corrected: December 31, 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: An unlabelled and open bag of biscuit was stored in the dining area servery drawer. Unlabelled and uncovered ensure in cups found inside the medication fridge.
Corrective Action(s): Please ensure that food is safely stored.
Date to be Corrected: December 31, 2022.
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