PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: During inspection it was noted that:
Main North
Tubroom had soap and rust on top of the metal shelf next to the tub
Physio Therapy area - chair had a strong urine smell
Foam fall mats in 5 PIC's rooms were stained and damaged and did not appear to be cleanable
Corrective Action(s): ensure all equipment is maintained in a safe clean condition
Date to be Corrected: April 2 2020
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:
Main North:
Water damage to the ceiling above the nursing station
Nursing station counter paint is worn down to the wood
2150 - Baseboard was worn down to the wood
2107 - Damage to the door worn down to the wood
2144 - Damage to door missing paint
Dining area - cement poles missing paint at the bottoms
2252 - Floor damage broken vinyl missing a section of the floor, baseboard damages
2247 - soiled room, missing paint damaged drywall
Lower North:
1145 - Wall damages to paint and drywall
1138 - Wall damages to drywall missing down to the metal on corners
Dining area - walls and baseboards are scuffed, missing paint and some drywall damage
East wing:
Washroom - missing baseboards
1210 - missing baseboards
1238 - wall damages missing paint and drywall
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: Provide a schedule of completion By April 2 2020
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: During inspection it was noted that:
Main South
- Toilet area had boxes in it and was being used as a storage area
Main North
Tubroom - Shower chair had hair on it and a washcloth was stuck on the back of the seat
2 outside decks were mossy and had leaves and dirt on them
2224 - ceiling is dirty where the heat vent blows out on it
Lower North
Tubroom - toilet was dirty
Corrective Action(s): Ensure all rooms and common areas are maintained in a safe and clean manner
Date to be Corrected: April 2, 2020
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Inspection of the facility found:
Main North
Tub room - Cleaners not stored or secured
Lower North
Tub room - Cleaners not stored or secured
Corrective Action(s): Ensure all cleaners and chemicals are stored in a secured area
Date to be Corrected: April 2 2020
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: Review of the medication systems found:
A prescribed cream was found in a PIC's room. It is listed on the MAR and has been documented as being applied twice daily
Medication cart was left unlocked while care staff administered medications away from the cart
Corrective Action(s): Ensue all medications are safely and securely stored
Date to be Corrected: April 2 2020
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation:
Medication fridge on Main North was missing 2 days of temperature readings for the fridge
3 nitro sprays were unlabeled in medication boxes
LPN on Main South had removed all noon medication pouches from the rolls and placed them in a cup and indicated she planned to dispense from there. She indicated this is her typical practice
Corrective Action(s): Ensure that policies are implemented by employees
Date to be Corrected: April 2 2020
CARE AND/OR SUPERVISION: 34050 - RCR s.47(2)(c) - A licensee must consider, as part of the screening process under subsection (1), all of the following: (c) the needs of the person, including any needs that should be identified specifically in a care plan.
Observation: Review of 10 care plans found 1 PIC's care plan had an incomplete dementia assessment
Corrective Action(s): Ensure all assessments are completed as part of the screening process
Date to be Corrected: April 2 2020
CARE AND/OR SUPERVISION: 34470 - RCR s.73(2)(c) - In addition to the requirements under subsection (1), the following conditions apply to the use of a restraint under section 74(1)(b) [when restraints may be used]: (c) the use of the restraint, its type and the duration for which it is used must be documented in the care plan of the person in care.
Observation: Review of care plans found 1 PIC 2515 was missing the restraint agreement although they are using a lap belt and tilt chair
Corrective Action(s): Ensure all requirements are met for use of a restraint
Date to be Corrected: April 2 2020
CARE AND/OR SUPERVISION: 34670 - RCR s.81(3)(e)(i) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (i) an assessment of the nature of the risk of falling presented by the person in care.
Observation: Review of 10 care plans found 1 care plan had an incomplete falls assessment form
Corrective Action(s): Ensure all falls assessments are completed and information is complete in the care plan
Date to be Corrected: April 2 2020
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: Review of 10 persons in care's care plans found that 1 PIC had another PIC's wound care plan and photos in their binder
Corrective Action(s): Ensure that the care plans are monitored regularly to ensure proper information is included in the plans
Date to be Corrected: April 2 2020
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 person's in care admissions information found that 7 of 10 were missing immunization and TB documentation
Corrective Action(s): Ensure all PIC's comply with the provinces immunization and Tuberculosis programs
Date to be Corrected: April 2 2020
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: During the inspection it was noted that:
Main South - tub room
- an unlabeled bar of soap was left out on a shelf in the tub room
Main North - tub room
- 2 PIC body washes and 1 shampoo were left in the tub room
- an open box of nail files were out on the shelf and spilled out
- in the clean room old combs were being saved
- Hair elastics with hair on them left on the shelf
- 1 set of unlabeled nail clippers
Lower North- tub room
- 2 sets of nail clippers unlabeled
- 1 unlabeled shaver
- 1 set of unlabeled broken scissors
- 3 PIC's shampoos
Corrective Action(s): Ensure all tub rooms are maintained in a clean manner and all hygiene products are stored, labeled and used in a hygienic manner
Date to be Corrected: April 2, 2020
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 food storage and food service areas found
Main North - medication room fridge was dirty ( used for medication related foods)
Kitchen - Waffle package on the floor in the corner of the fridge
Main South
- A bunch of bananas were sitting on a hand rail in the dining area
- Fridge was warm and ice-cream in the freezer was soft, thermometer did not appear to be working
- Fridge on the lower floor dining area had consistent temperatures recorded that were not in the safe zone (10 degrees)
Corrective Action(s): Ensure all food is stored, served and handled safely
Date to be Corrected: April 2, 2020
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