PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31740 - RCR s.35(1)(a) - A licensee must provide the following appropriately furnished and equipped areas: (a) work areas for administrative work and other staff use.
Observation: The office chairs present in the administrative area of each neighborhood were observed to be torn, worn, with foam exposed in some examples. The chairs are in the public area, appear poorly maintained and cannot be sanitized.
Corrective Action(s): Please ensure that furnishings that create the resident environment are maintained in an appropriate manner.
Date to be Corrected: Oct. 18, 2017
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31750 - RCR s.35(1)(b) - A licensee must provide the following appropriately furnished and equipped areas: (b) safe and secure locations for medications and the records of persons in care.
Observation: Polysporin ointment was observed in an unsecured cabinet in 2 resident's bathroom. One resident is reported as being very independent and may well benefit from a plan for medication self administration for this product. Liquid petrolatum was also observed in an unsecured cabinet.
Corrective Action(s): Please provide a plan that will ensure that all medication is safely and securely stored. Please, also, determine the purpose of the liquid petrolatum in order to determine if it may pose a hazard.
Date to be Corrected: October 18, 2017
STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person.
Observation: of 5 staff files reviewed 2 had CRC last dated 2011.
Corrective Action(s): Please provide a plan that will ensure that there is a system to identify staff who require a CRC update in a timely manner in order that it allows time for the staff to renew.
Date to be Corrected: October 18, 2017
STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Of 6 staff records reviewed, the performance reviews that could be observed were most recently in 3 files were dated 2007 and 2005., In review of this issue with the DOC she was able to show that the majority of all staff have had a perfomance review in the last year. There has been no Human Resources staff for a year and there has been a backlog of filing. There is only a small number of reviews yet to be completed.
Corrective Action(s): Please provide a plan for completion of the outstanding performance reviews and a plan for how the bi-yearly reviews will be completed as per Buchanan policy in the future.
Date to be Corrected: Oct. 18, 2017
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: in 2 files observed, no completed assessment of immunization status was observed.
Corrective Action(s): Please provide a plan that will ensure that as per the regulation above all persons admitted to the licensed facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: October 18, 2016
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: In a first floor shower room, there were unlabelled razors and electric razors, unlabelled soap bars, (4) in a zip lock bag, a used razor in the shower caddy posing a laceration hazard, a cardboard box on a chair containing unlabelled personal bathing and shaving products. In cupboard under the blanket warmer, a pink zipper bag with an electric razor, 4 hairclips on the counter. In 2 bathrooms observed there were articles of clothing in the bathing room drawers. Labelling was not observed as writer did not pull the articles out of the drawers.
In a second floor tub room, a necklace under the tub lift chair and a "Caprice" watch was observed in the shower area. A chrome tubular shelf was observed to have soap scum and rust covering it. The small drawer unit intended to hold individual nail clippers was observed to contain the nail clippings of 6 residents.
There was a Gomco Suction in the nurse's storage room containing a selection of non-labelled shaving materials both electric and plain razors.
Corrective Action(s): Please provide a plan that will ensure that the owner of all products for the bath/grooming areas are identified appropriately and that sanitary storage practices are maintained. The plan should also include instructions on the interpersonal use of shaving materials for equipment used between PICs (Gomco).
Date to be Corrected: Oct. 18, 2017
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: A container of food was observed in a medicine cabinet, there was unlabelled cheese in a servery fridge, unlabelled and opened ensure product was observed in another. A large container of pudding was observed in a med fridge, with 2 small containers, none were labelled with date one was not covered. The servery fridge in Rose Garden was observed to cool to 5-8.5 degrees celsius, well above temperatures recommended by Food Safe. The bags of tube feeding liquid were stored in a box on the floor of the nurse's storage room close to where a floor mop may come in contact.
Corrective Action(s): Please provide a plan that will ensure that all foods for consumption by residents is appropriately stored and labelled.
Date to be Corrected: Oct. 18, 2017
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: This facility does not include the snacks on the printout of the menu. Snacks are posted on the bulletin board of each neighborhood. A cart is pushed around the public areas at 2:30 and 7:00. The cart does not go into rooms of residents to offer snacks unless the resident has a prescribed snack. Residents who are resting in their rooms therefore are not offered the opportunity of a snack and this does not meet the intent of the regulation for those residents who are not able to come out of their rooms independently to get the snack.
Corrective Action(s): Please provide a plan that will ensure that the intent of the regulation can be met.
Date to be Corrected: Oct. 18, 2017
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