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: The water temperature in the first floor kitchen washroom used by persons in care was 51 degrees Celsius.
Corrective Action(s): Please ensure that the water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Date to be Corrected: June 28, 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: Doors of two clean utility rooms and three soiled utility rooms were left open.
Corrective Action(s): A licensee must secure the utility rooms.
Date to be Corrected: July 18, 2022
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: One of 8 staff did not have the character references on file.
Corrective Action(s): Please ensure that employees in a community care facility has obtained a character references on file.
Date to be Corrected: July 31, 2022
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: One of 8 staff files did not have the evidence of compliance to Province's immunization and TB on file.
Corrective Action(s): Please ensure that all employees in the community care facility provide evidence of compliance to Province's immunization and tuberculosis control program.
Date to be Corrected: August 30, 2022
STAFFING: 32081 - RCR s.37(3)(a) - Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: (a) a criminal record check for the person;
Observation: One volunteer has an expired criminal record check on file.
Corrective Action(s): A licensee must ensure that all volunteers have a valid criminal record check.
Date to be Corrected: July 18, 2022
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: The Licensee's policy and procedure required staff's performance reviews are completed every 3 years. One of 8 staff had the last performance review in 2014.
Corrective Action(s): Staff performance review must be completed according to the licensee's policies and procedures.
Date to be Corrected: August 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: Three medication count sheets were missing 20 second signatures in June 2022. Medication refrigerator temperature were not recorded 10 times in June 2022, temperature has to be monitored twice a day
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the mediation safety and advisory committee.
Date to be Corrected: July 18, 2022
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: Two of 9 persons in care has no signed consent from medical practitioner or nurse practitioner for the use of restraint on file.
Corrective Action(s): Please ensure that there is an agreement to the use of a restrain given in writing by medical practitioner or nurse practitioner responsible for the health of the PIC.
Date to be Corrected: July 18, 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: The licensee's policy and procedure required that the staff must record refrigerator temperature, two servery refrigerator temperature was not recorded 8 times in June 2022 and kitchen refrigerator temperature was not recorded 3 times in June 2022. A staff lunch bag was found inside the kitchen refrigerator.
Corrective Action(s): A licensee must ensure that policies are implemented by employees.
Date to be Corrected: July 18, 2022
CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: Seven of 9 persons in care has no dental consult on file and no evidence to support encouragement.
Corrective Action(s): A licensee must encourage the person in care to be examined by a dental health care professional at least once every year.
Date to be Corrected: October 30, 2022
CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: Nine of 9 persons in care has no recreation and leisure plan. In discussion with the recreation manager it was determined that persons in care (PICs) are participating in the activities, however the activities were not included in the PIC's care plans.
Corrective Action(s): Please ensure that care plans include a recreation and leisure plan for all persons in care.
Date to be Corrected: October 30, 2022
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: The diet texture served was not in accordance to the nutrition care plan to two persons in care.
Corrective Action(s): A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Date to be Corrected: July 18, 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: One of 9 PICs has no evidence of compliance to Province's immunization and tuberculosis control programs.
Corrective Action(s): A licensee must require all person admitted to community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: July 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: Two unlabelled plate of food covered in cling wrap were stored in first floor servery refrigerators. An unlabelled sandwich covered in cling wrap was found in the kitchen's refrigerator.
Corrective Action(s): Please ensure that all food is safely stored.
Date to be Corrected: July 18, 2022
NUTRITION AND FOOD SERVICES: 37140 - RCR s.64(1)(c) - A licensee, other than a licensee who provides a type of care described as Child and Youth Residential, must ensure that (c) an evening meal is served after 5:00 p.m.
Observation: Two of 4 units were serving dinner at 4:45 p.m.
Corrective Action(s): Please ensure that evening meal is served after 5:00 p.m.
Date to be Corrected: July 18, 2022
RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: Snack menu has assorted home-baked goods and fruit tray listed, record of daily or weekly snack items was not available.
Corrective Action(s): Please ensure that snack menu has variety of snack choices on record available to persons in care.
Date to be Corrected: July 18, 2022
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