LICENSING: 30030 - RCR s.8(2)(a)(ii) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (ii) a description of how the licensee intends to ensure the health and safety of persons in care while the change is being made.
Observation: One dining area has the air conditioner replaced but no submission and acceptance from Licensing of PICs health and safety plan.
Corrective Action(s): A licensee must not make any structural change to a community care facility unless the licensee first submits to a medical officer a description of how the licensee intends to ensure the health and safety of persons in care while the change is being made.
Date to be Corrected: September 29, 2023
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: One PIC spa room has bottles of disinfectant cleaner on top of the sink countertop.
Corrective Action(s): Please ensure to have a secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Date to be Corrected: September 29, 2023
STAFFING: 32081 - RCR s.37(3)(a) - Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: (a) a criminal record check for the person;
Observation: One volunteer has no criminal record check on file.
Corrective Action(s): A licensee must ensure that all volunteers have a criminal record check on file.
Date to be Corrected: September 29, 2023
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: One person in care's restraint consent was not renewed and signed by medical practitioner as scheduled.
Corrective Action(s): Please ensure that there is an agreement to the use of a restrain given in writing by medical practitioner or nurse practitioner responsible for the health of the PIC.
Date to be Corrected: September 29, 2023
CARE AND/OR SUPERVISION: 34160 - RCR s.54(2)(a) - A licensee must (a) assist persons in care to obtain health services as required.
Observation: A medication ordered by medical practitioner for 2 persons in care was not processed until its 3rd day and 7th day.
Corrective Action(s): Please ensure that persons in care are assisted in obtaining health services as required.
Date to be Corrected: September 29, 2023
CARE AND/OR SUPERVISION: 34390 - RCR s.63(5) - A licensee must ensure that persons in care have sufficient time and assistance to eat safely and comfortably.
Observation: During lunch, one person in care (PIC) was observed being fed by staff who was standing. Standing while assisting to feed the PIC does not align with safe feeding practices.
Corrective Action(s): Please ensure that persons in care have sufficient time and assistance to eat safely and comfortably.
Date to be Corrected: September 29, 2023
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Three unlabelled food in a container stored in the refrigerator.
Corrective Action(s): Please ensure that food is safety stored.
Date to be Corrected: September 29, 2023
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation (CORRECTED DURING INSPECTION): One of 6 medications rooms had PIC's expired medications.
Corrective Action(s): Please ensure to return person in care's medication to the dispensing pharmacy if the expiry date on the medication has passed.
Date to be Corrected: September 29, 2023
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