PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: The following were observed:
1). A electrical socket is missing the cover in the basement kitchen.
2). The fridge in the basement kitchen has excessive ice buildup. Staff said that the problem has been there for a several months.
Corrective Action(s): Please ensure that all equipment for the PIC's use is maintained in safe and good state of repair.
Date to be Corrected: January 3, 2023
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: A controlled medication was found stored in a ziplock bag in the medication cupboard that was not double locked.
Corrective Action(s): Please ensure that all medications in the facility are safely and securely locked according to the MSAC procedures.
Date to be Corrected: Dec 19, 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 LO was informed during the inspection that casual staff performance reviews have not been completed.
Corrective Action(s): Please ensure that the staff performance reviews are completed as per the facility policy.
Date to be Corrected: January 3, 2023
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: Emergency menu was not available during the time of inspection.. The staff assisting with the inspection have been shown the emergency menu planning from Meals and More
Corrective Action(s): Please ensure that an emergency plan including a menu that sets out procedures to prepare and mitigate, recover and respond to any emergency situation is available for a minimum of 3 days.
Date to be Corrected: January 3, 2023
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 policy and procedures have not been reviewed this year. The staff assisting with the inspection have been asked to review and date the policy manual to make it current if no revision has occurred.
Corrective Action(s): Please ensure that policies and procedures are reviewed at least once each year.
Date to be Corrected: January 3, 2023
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 menu substitution was only completed twice within this fiscal. A discussion with the staff assisting with the inspection found that PICs are having different menu and eating out so menu substitution is occurring but not being entered by staff.
Corrective Action(s): Please ensure that staff complete the menu substitution form appropriately.
Date to be Corrected: January 3, 2023
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: 1/4 PIC's care plan did not include the latest instructions for the appropriate care of this PIC after his circumstances have changed several month ago leaving him more dependent and unable to participate in set activities..
Corrective Action(s): Please ensure that each care plan is reviewed annually and modified appropriately with any substantial change in the circumstances of the PIC.
Date to be Corrected: January 3, 2023
MEDICATION: 36160 - RCR s.72(a) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (a) the person in care is no longer taking the medication.
Observation: A medication that was discontinued for the PIC was found in the medication cupboard even though the pharmacy has come in to restock new medications after the discontinuation was effected the medication was not returned.
Corrective Action(s): Please ensure there is a plan in place to return a PIC's medication to the dispensing pharmacy if a PIC is no longer taking the medication.
Date to be Corrected: January 3, 2023
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: Nutrition Screening Form have not been completed for a PIC whose nutritional needs have changed several months
Corrective Action(s): Please ensure that Nutrition Screening Forms are completed at least once a year for a PIC and the results of the screening forms are documented in the overall care plan to meet the intent of this legislation.
Date to be Corrected: January 3, 2023
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