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 5 bedroom sinks used by persons in care varies from 55 to 57 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: April 26, 2024
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 4 medication rooms, found 3 insulin medication with no date when it was opened, this medication can be stored outside the fridge for 28 days, PRN medication effectiveness were not recorded to 9 persons in care (PIC), medication administration record for 2 PICs' regular medications has no signature nor code written and 2 medication count sheets has missing second signature.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: April 26, 2024
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: Three persons in care wound treatment care plan were not followed as scheduled. As per staff treatment was provided but not documented.
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: April 26, 2024
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: Fourteen of 15 persons in care has no evidence of compliance to Province's immunization and tuberculosis control programs on file.
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: April 26, 2024
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Five of 15 persons in care does not have the monthly weight taken consistently.
Corrective Action(s): Please ensure that the each person in care is weighed at least once each month.
Date to be Corrected: April 26, 2024
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