PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: Two persons in care wood dressers has its surface 40% peeled and chipped. Arm rests of 2 leather couch and 6 chairs has its surface lining removed.
Corrective Action(s): Please ensure that all furniture and equipment used by persons in care are maintained in a good state of repair.
Date to be Corrected: December 15, 2022
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: One person in care's bathroom floor vinyl measures 7 inches by 6 inches came off. Vinyl floor in first floor hallway measures 9 inches x 2 inches came off. Two ceiling tiles in first floor spa room has evidence of water leak. Wood hand rails through out the facility has chips and scuffs potential for splinters. One metal door protector and one baseboard in first floor were sticking out requiring reattachment.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: December 15, 2022
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: Two of 10 staff has no performance review document on file.
Corrective Action(s): Please ensure that performance of each employee is reviewed regularly.
Date to be Corrected: September 15, 2022
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: Two of 10 staff has no valid first aid and CPR certificate on file.
Corrective Action(s): A licensee must ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate.
Date to be Corrected: September 15, 2022
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: The insulin medication has no date when it was opened. One medication count sheet were missing 17 second signatures for July and August 2022. Two medication refrigerator temperature were not recorded 12 times in August 2022.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: August 29, 2022
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: The licensee's policy and procedure required that staff must record the refrigerator temperature, three servery refrigerator temperature was not recorded 9 times in total for August 2022.
Corrective Action(s): A licensee must ensure that policies are implemented by employees.
Date to be Corrected: August 29, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Food bars with expiration date March 2021 were stored in emergency supplies shed. Three unlabelled bins containing sandwiches stored in the servery and kitchen refrigerator. Two unlabelled containers with pudding stored in medication room refrigerator.
Corrective Action(s): Please ensure that all food is safely stored.
Date to be Corrected: August 29, 2022
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 person in care's medication with expiration date of June 2022 was still inside the medication cart.
Corrective Action(s): Please ensure that a person in care's medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Date to be Corrected: August 29, 2022
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