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: Inspection of the facility found there to be numerous areas throughout the site that are in need of paint and minor drywall repair. On all units inspected it was observed that the wall paint was chipping or had been scuffed and damage to the drywall was visible. Inspection of nursing work stations found that the doors were worn down to the bare wood. Of concern is the ability to effectively clean this surface.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: April 9, 2021
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: Review of 17 employee files found there to be 5 files where the evidence of compliance with the immunization and tuberculosis control programs, is incomplete.
Corrective Action(s): Ensure that all employees provide evidence of compliance with the Province's immunization and tuberculosis control programs.
Date to be Corrected: April 6, 2021
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: Review of medication administration and documentation practices found that the narcotic count book was missing evidence of a double signature, as required by the medication administration policy. Review of 3 medication rooms found that over the past month, there were at least 6 dates where signatures were missing.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: April 6, 2021
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: Review of PIC care plan, specifically wound care, found that on 4 occasions documentation of treatment provided was not in accordance with the treatment plan frequency.
Corrective Action(s): Ensure that care provided is consistent with the terms and conditions of the PIC's care plan
Date to be Corrected: April 6, 2021
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: Review of 10 persons in care (PIC) records found that 5 were missing evidence of compliance with the Province's immunization and/or tuberculosis control programs.
Corrective Action(s): Ensure that all persons admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: April 6, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Inspection of 3 refrigerators found there to be a temperature monitoring system in place. It was however noted that the recorded temperatures were sometimes outside the safe zone, were sometimes recorded using Fahrenheit, sometimes using Celsius, and there were instances where the temperature was not recorded at all. Of concern is on the occasions where the temperature was found to be outside the safe zone, there is no evidence that action was taken. Additionally, it was suggested to avoid the potential for confusion, temperatures should be recorded using Celsius.
Corrective Action(s): Ensure that food is safely stored.
Date to be Corrected: April 6, 2021
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