LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: A review of the care planning system indicated for example the care flow sheets (e.g. Oral Care during the "D" (days) not initialed by staff and specifics provided to the Manager/Director of Care).
Corrective Action(s): Please ensure the physical environment of the community care facility, and the care and services provided by it are monitored to ensure that the requirements of the Act and this regulation are being met.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: The facility has self identified that the nurses stations in both neighbourhoods need to be addressed and upgraded (e.g., Garden Avenue nurses station before entering the nurses station the counter edges, the wood is showing as the material covering the wood has come off). However due to the pandemic this work has been put on hold and the Manager/Director of Care is aware that a health and safety plan needs to be submitted to Community Care Facilities Licensing for review and approval before any work starts.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: As this item is on hold given the pandemic, the Manager/Director of Care is aware of submitting a health and safety plan to Community Care Facilities Licensing for review and approval before any work starts.
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: A review of the care planning system indicated on the front of the medication administration record for a person in care (specifics provided to the Manager/Director of Care), entries not charted by the staff. The Manager/Director of Care was able to go back to the progress notes and for one entry there was information present. The Manager/Director of Care will review the remaining entries as to why they are not charted for.
In addition, there were narcotic drug count sheets (specifics provided to the Manager/Director of Care), whereby for example the second nurse signature/initials are not documented. The Manager/Director of Care confirmed that two signatures/initials are required for the narcotic drug count sheets.
Corrective Action(s): Please ensure all staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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