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: water temperature in room 200 was noted to be 51 degrees Celsius while water in the south side of the building measured 40 degrees.
Corrective Action(s): Please provide a plan that will ensure that all areas for hot water distribution throughout the building to which PICs access do not exceed 49 Degrees Celsius
Date to be Corrected: Feb. 21, 2019
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: A record of review of the currency of performance reviews for staff in all departments was provided. Food services, dietary and laundry have recorded 0-10 percent staff performance reviews since 2015. Care staff P/A reviews show completion rates of 20-56% with the exception of LPN's who were reviewed at 125%. The facility policy indicates that yearly review is to be conducted at the discretion of the DRC.
Corrective Action(s): Please provide a plan of achievable/sustainable performance review intervals, and a plan to meet the policy objective for this year.
Date to be Corrected: Feb. 21, 2019
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: Only one SPA/Tub room was inspected. There was a large multi-use pump container for shampoo, there was an unlabelled personal shampoo bottle wedged in the shower railing. Nail clippers though unlabelled were in a small drawer cabinet with the person and room labelled.
Corrective Action(s): Please ensure that personal use products are labelled with the PIC name, and that there is a system for using the multiple use products that will ensure that there is no opportunity for the pump to vector contamination.
Date to be Corrected: Feb. 21, 2019
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