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 the laundry room it was noted that part of the floor had no flooring, instead, the wooden sub-floor was exposed. Persons in care do not access this room, however on the day of inspection, the door was open.
Below the window in the living room it was noted several black marks and scratches in the wall.
The floor in the shower room appears to have been painted, with chips of paint starting to lift and come off.
A patched part of the wall in the shower rooms needs to be painted as dry-wall mud is exposed.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: October 22, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: The Licensee has established a system where the emergency supplies are to be inspected and signed for monthly, however in 2020, this was completed only 9 of the 12 months and in 2021, only 3 of the 9 months so far.
Corrective Action(s): Please ensure the emergency supplies are inspected and signed for as per the Licensee's own system.
Date to be Corrected: October 22, 2021
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: During the inspection it was observed that one of the two medication cabinets was left unlocked, while the second was unlocked with the keys still in the lock.
Corrective Action(s): Please ensure that at all times, medications are securely stored.
Date to be Corrected: Immediately.
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: The Licensee's Reportable Incident policy was reviewed and it was determined that it did not instruct staff to report Aggression between persons in care as outlined in Schedule D of the Residential Care Regulation. In addition, it contained reporting methods that changed in 2019, from paper submission to on-line.
Corrective Action(s): Please ensure that policies are revised and reviewed at least once each year.
Date to be Corrected: October 22, 2021
POLICIES AND PROCEDURES: 33390 - RCR s.85(2)(g) - Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: (g) monitoring of the nutrition of a person in care.
Observation: In a review of the policies and procedures available, one regarding the monitoring of the nutrition of a person in care could not be found.
Corrective Action(s): Please ensure that the Licensee has written policies and procedures regarding the monitoring of the nutrition of persons in care.
Date to be Corrected: October 22, 2021
CARE AND/OR SUPERVISION: 34150 - RCR s.53 - A licensee must, to the greatest extent possible while maintaining the health, safety and dignity of all persons in care, ensure respect for the personal privacy of each person in care, including the privacy of each person in care's bedroom, belongings and storage area.
Observation: A bed was observed to be present in a common living area of the facility (Living/dining room with open concept kitchen attached). When asked, staff informed CCFL that the bed was used by one person in care (PIC). It was discussed that this was so that the PIC could still participate in activities while resting in the bed and staff could observe the PIC at their convenience. If needed, care would be provided in the bed. The bed is directly beside windows that face the back yard and a neighboring home and while there are coverings on the window, they are no curtains to provide privacy to the rest of the home. The PIC that uses the bed, does have a bedroom that affords complete privacy as required. A review of the protocol for the use of the bed contained no previsions for care while in the bed or privacy for staff to follow.
Corrective Action(s): Please ensure that to the greatest extent possible, all PIC are provided with privacy.
Date to be Corrected: October 22, 2021
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: Substitution list was reviewed, and it was found that when an item was substituted from the menu, that an item from the same food group with similar nutritional value, was not always used. For example, on one occasion, fries was used in place of pasta.
Corrective Action(s): Please ensure that substitutions be made from the same food group and have similar nutritional value.
Date to be Corrected: October 22, 2021
RECORDS AND REPORTING: 39190 - RCR s.78(2)(a) - A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care.
Observation: A review of one PIC Medication Administration Record (MAR) showed that on two different days, one medication was administered, however not signed for and on a third day, all their morning medications were administered, but not signed for.
Corrective Action(s): Please ensure that a record for all medications administered is maintained.
Date to be Corrected: October 22, 2021
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 record of audits for the current 4 week menu used by the facility was available on request during the inspection, when asked, it was confirmed that the current menu was not audited.
Corrective Action(s): Please ensure records are kept of food services monitoring.
Date to be Corrected: October 22, 2021
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