PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: In the tub room it was observed that the caulking where the tub and tile meet, had a dark substances growing on it that appeared to be mildew. Around the base of the tub, where the tub and the floor meet, the caulking was cracked and covered with the same dark substance.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: Feb 17, 2023
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: Discussion with staff determined that staff performance reviews are due, and not yet completed, as per timeline requirements in the policy.
Corrective Action(s): Ensure that the performance of each employee is review regularly, and as required by the facility's policy, to ensure that employees continue to meet the requirements of this regulation.
Date to be Corrected: Feb 17, 2023
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: 3 person in care records were reviewed, and the following was found:
-For 1 person in care a supplement that had been ordered by a doctor, had a handwritten MAR, and the persons own supply was provided and had not been listed on the MAR and the supplement was not labelled by the pharmacy, as required in the facility's policy.
-For a 2nd person in care, there was a hand written MAR for one medication. It was described that the pharmacy did not include the medication on the MAR for the month of February.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the MSAC.
Date to be Corrected: February 17, 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: Discussion with staff determined that the emergency supplies had expired, and the new supplies have been ordered but have not yet arrived. So the facility does not currently have emergency supplies to respond to and recover from an emergency.
Corrective Action(s): Ensure that there is a plan and preparation to mitigate, respond to and recover from any emergency.
Date to be Corrected: Feb 17, 2023
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: The facility does not have a current menu and menu audit of the foods being provided by the contracted food provider. There has been recent changes in services and menus and audits have not been made available to the facility.
Corrective Action(s): Ensure that records are kept regarding food services, including current menus, and the audits of those menus.
Date to be Corrected: Feb 17, 2023
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