PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Inspection of the facility found the three tub/spa rooms that were not in use, were unlocked and the doors were left open. Discussion with the facility DOC determined that tub rooms doors should remained closed and locked when not in use.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe condition.
Date to be Corrected: June 25, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: Inspection of the facility found that 5 fire extinguishers were expired in March 2018.
Corrective Action(s): Ensure that all emergency equipment is inspected and maintained on a regular basis.
Date to be Corrected: June 25, 2018
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: Inspection of the secured floor unit found that personal items were stored in the medication closet. Discussion with the GM and DOC determined that this does not comply with the facilities MSAC policies and procedures.
Corrective Action(s): Ensure that personal items are not stored in the same secure area as medications.
Date to be Corrected: June 25, 2018
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: Review of 2 of 6 care plans found that 2 persons in care (PIC) had experienced significant weight losses. It could not be determined by the documentation provided, if the care plans were reviewed or modified to reflect these PIC's weight changes.
Corrective Action(s): Ensure that any substantial changes are reflected in the care plan.
Date to be Corrected: June 25, 2018
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: Review of 1 of 6 person in care (PIC) found no documentation in the point of care records to confirm that the PIC's skin check was completed in May.
Corrective Action(s): Ensure that all care and supervision of PIC's is consistent with the terms and conditions of the PIC's care plan.
Date to be Corrected: June 25, 2018
CARE AND/OR SUPERVISION: 34890 - RCR s.83(4)(b) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (b) immediately seek the advice of a health care provider if the person in care has experienced, unintentionally, a significant change in weight,
Observation: Review of 5 of 6 person in care (PIC) weights found that there was significant weight changes from month to month for 5 PIC's. It could not be determined by the documentation provided if immediate advice was sought from the appropriate health care provider.
Corrective Action(s): Ensure that documentation reflects when advice from a health care provider is requested due to significant changes in PIC's weights.
Date to be Corrected: June 25, 2018
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 2 of 6 person in care (PIC) care plans found that there was no past immunization history documented.
Corrective Action(s): Ensure that all PIC's admitted comply with the Province's immunization control programs.
Date to be Corrected: June 25, 2018
RECORDS AND REPORTING: 39160 - RCR s.78(1)(d) - A licensee must keep, for each person in care, a record showing the following information: (d) information by which the person in care may be described or identified in an emergency, including a photograph.
Observation: Review of 1 of 6 person in care (PIC) records found that there was no photograph for the PIC who had been admitted two weeks ago.
Corrective Action(s): Ensure that care plan records are complete.
Date to be Corrected: June 25, 2018
RECORDS AND REPORTING: 39580 - RCR s.91(1)(a) - A licensee must ensure that all records referred to in this regulation (a) are current.
Observation: Review of 3 of 8 employee records found that the professional staff registrations were expired on 2016 and 2017.
Corrective Action(s): Ensure that all employee records are complete.
Date to be Corrected: June 25, 2018
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