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: During inspection the LO observed:
- laminate counter has a piece missing in one bathroom
- caulking in 2 of the bathtubs appears yellow and has spots of black
- the plastic tubing connecting one of the shower heads is discoloured
- in one of the shower rooms the tile and grout is discoloured (the MOC reported that capital funding to replace the tile in this room was requested in Feb 2016 but denied)
- laminate floor in the gym is peeling (the MOC reported that this is scheduled for replacement and will be completed by the end of June 2016)
- the cabinet in the meeting room space has door handles missing
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: June 30, 2016
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 (CORRECTED DURING INSPECTION): Review of 5 staff files found that 1/5 did not include immunization and TB records.
Corrective Action(s): The MOC was able to have the staff complete the forms while the LO was present.
Date to be Corrected:
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 30 PRN medications documented found 8/30 did not have the results documented as required in the PRN medication documentation policy
Corrective Action(s): Ensure all employees comply with medication policies
Date to be Corrected: June 30, 2016
CARE AND/OR SUPERVISION: 34900 - RCR s.83(5)(a) - If a person in care refuses or is unable to be weighed, the licensee must (a) record in the nutrition plan of the person in care the reason why the person in care was not weighed.
Observation: Review of the weight chart found 2 missing weights in March and several in May 2016 with no notes as to why they were not recorded. It was confirmed that one of the missing weights was due to a PIC in the hospital
Corrective Action(s): Ensure that documentation is completed for all missed weights as to why it was missed
Date to be Corrected: June 30, 2016
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Leftovers were found in containers of two fridges, without any labelling of contents and date
Corrective Action(s): Ensure that all leftovers are labelled.
Date to be Corrected: June 30, 2016
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: The snacks available for the PIC's is currently only fruit. The staff reports that other food is available if the PIC's request it, but it is not prepared and put out for them.
Corrective Action(s): Ensure that PIC's have two snacks available per day containing 2 food groups
Date to be Corrected: June 30, 2016
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: In reviewing the substitution list, there was one occasion where fish was substituted with macaroni and cheese, which are not in the same food group.
Corrective Action(s): Ensure that all food substitutions are of the same food group with similar nutritional value
Date to be Corrected: June 30, 2016
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Review of 2 PIC records found that 0/2 had the consent for emergency services. The MOC was able to show the LO the updated form that included this consent, and found that new intakes did have this form in their files.
Corrective Action(s): Ensure all current and future PIC's have the consent for emergency services in their file
Date to be Corrected: June 30, 2016
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (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: Review of the weight records for residents found that April 2016 was missed as the facility dietician was on leave. The casual dietician was brought in for May.
Corrective Action(s): Ensure all weights are taken monthly
Date to be Corrected:
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