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 wood hand rail in first floor entrance has the corner chipped exposing rough edges and a risk for splinters measuring 4x2 inches. A cabinet below the sink in 1st floor dining room that would not close completely and a wall where the food cart was stored was chipped measures 4x3 inches and 2x2 inches. A duct covering was removed in the PICs toilet room, it requires reattachment. A dry wall in the small dining room was chipped measures 5x3 inches and 3x2 inches.
Corrective Action(s): Please ensure that all rooms and commons areas are maintained in a good state of repair.
Date to be Corrected: December 19, 2022
STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Two of 10 staff files did not have evidence of compliance with the Province's immunization and tuberculosis control programs.
Corrective Action(s): Please ensure that all employees in a community care facility provide evidence of compliance with the Province's immunization and tuberculosis control programs.
Date to be Corrected: December 19, 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 the performance of each employee is reviewed regularly
Date to be Corrected: December 19, 2022
STAFFING: 32260 - RCR s.44(1)(b) - A licensee must ensure that employees responsible for the preparation and delivery of food (b) receive ongoing education respecting the preparation and delivery of food, nutrition and, if required, assisted eating techniques.
Observation: One dietary staff does not have a food safe certificate on file.
Corrective Action(s): Please ensure that employees responsible for the preparation and delivery o food receive ongoing education respecting the preparation and delivery of food, nutrition and , if requires, assisted eating techniques.
Date to be Corrected: December 19, 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 found in medication cart has no date when it was opened, this medication has a pharmacy label that can be stored outside of the fridge for 28 days. Medication refrigerator temperature was not recorded 7 times in November 2022, temperature has to be monitored twice daily.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: December 19, 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: A dietary staff was not using the nutrition/diet guide as reference in dishing out food in the dining area.Three kitchen refrigerator temperature was not recorded 21 times in November 2022. A staff lunch bag was found inside the small dining refrigerator.
Corrective Action(s): Please ensure that policies are implemented by employees.
Date to be Corrected: December 19, 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: Three contingency medications for persons in care were expired.
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: December 19, 2022
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