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: The bathroom immediately accessible in the lower lounge has been decommissioned, and the sink, tub, toilet have all been removed and stripped down to the concrete. Of concern is there are exposed wires hanging down from the ceiling, and venting exposed, and the area is not secured and open to the lounge space.
Corrective Action(s): Please submit a health and safety plan to licensing, and wait for written approval before commencement of work.
Date to be Corrected: May 9, 2023
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31200 - RCR s.19(3) - If a licensee installs electronic devices for the purposes of transmitting or recording images of persons in care or members of the public, the licensee must display in a prominent place notice that electronic surveillance is being used.
Observation: Cameras are located on the outside of this building, however no notification of electronic surveillance has been posted.
Corrective Action(s): Please ensure that if electronic devices are used for the purpose of transmitting or recording images of PICs or the public, the licensee must display in a prominent place a notice that electronic surveillance is being used.
Date to be Corrected: May 19, 2023
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: Review of medications for 4 persons in care, the medication room, and MSAC polices found the following:
-the PRN effectiveness has been documented less than 50% of the time
-Medication rooms fridge temperature has not been consistently recorded, at minimum twice per day as required by the policy
Corrective Action(s): Ensure that all employees comply wit the policies and procedures of the MSAC
Date to be Corrected: May 19, 2023
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: Review of polices and discussion with staff determined the following policies have not been implemented:
-care plan/ service plan policy
-TB testing of PIC policy
-Nutrition policy
Corrective Action(s): Please ensure all policies are implemented by employees
Date to be Corrected: May 19, 2023
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: 1 of 4 persons in care records reviewed, there had been a substantial change in circumstance that had not been reflected in the care plan. 2 other persons in care had oral care needs not reflected in their care plans.
Corrective Action(s): Ensure each care plan is reviewed and if necessary modified if there is a substantial change in the circumstance of the PIC.
Date to be Corrected: May 19, 2023
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Review of 4 persons in care records found that all 4 persons in care had incomplete immunization and TB screening records.
Corrective Action(s): Ensure that all persons admitted to a community care facility, comply with the Province's immunization and TB control programs.
Date to be Corrected: May 19, 2023
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: 4 person in care records were reviewed, 2/4 persons in care gave consent to be weighed monthly, both persons in care had not been weighed.
Corrective Action(s): Ensure that each persons in care is weighed at least once per month.
Date to be Corrected: May 19, 2023
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Review of the current menu and discussion with the manager determined that there is not a menu audit of the current menu being used.
Corrective Action(s): Ensure there is a menu audit of all menus being used, fall/winter, and spring/ summer menus, and records are kept regarding the monitoring of food and nutrition services.
Date to be Corrected: May 19, 2023
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