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: Last menu audit was completed in May 2020. Menu change occurred 2 years ago.
Corrective Action(s): Please ensure regular audits are completed to ensure the care and services being provided are being met.
Date to be Corrected: September 20, 2021
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: Of the seven PIC's bathroom hot water temperature, three recorded above 49 Celsius (52.2, 51.1 and 52)
Corrective Action(s): Please ensure the hot water temperature that the PIC access does not exceed 49C.
Date to be Corrected: September 6, 2021
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: Spa room ceiling tile (approximately 3ft X3 ft) has evidence of water damage which was confirmed by Leadership. Leadership stated that there is a plan to replace the ceiling tile.
Corrective Action(s): Please ensure all common areas are maintained in good state of repair.
Date to be Corrected: September 30, 2021
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: An unlabelled opened medication bottle with unknown white substance was located in a PIC's bathroom cabinet. Leadership could not determine what the substance was and how it was used by the PIC.
Corrective Action(s): Please ensure all medications are stored safely and secured.
Date to be Corrected: August 29, 2021
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: Five staff files were reviewed and 3 staff files did not have completed the performance evaluation within the last two years. The facility requires performance evaluations to be completed every two years as per their Policy and Procedure.
Corrective Action(s): Please ensure regular performance evaluation is conducted.
Date to be Corrected: October 31, 2021
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: MAR indicates on two occasions that the PRN effectiveness was not recorded. This is a requirement that is included in the facility's Medication Safety and Advisory Committee Policy and Procedure Binder.
Corrective Action(s): Please ensure staff follow the Policies and Procedures of proper documentation on the MAR
Date to be Corrected: August 30, 2021
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: All Policies and Procedures were last review was completed in October and November 2018 with one being reviewed in March 2019. Leadership stated that they are in the process of having an external department review the facility's Policy and Procedure Manual. Leadership could not provide an estimated time line for the review.
Corrective Action(s): Please ensure that Policies and Procedures are reviewed at least once a year and if necessary revised.
Date to be Corrected: November 1, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: One fridge located in the unit did not maintain the temperature recording from August 2 to 12th. The fridge is located within the servery area of the unit and stores food for the PIC. Leadership stated that the recording is to be done twice a day.
Corrective Action(s): Please ensure the system of recoding is maintained to ensure the food is being stored in a safely manner.
Date to be Corrected: August 31, 2021
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