PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: It was observed that a desk in the client lounge area that is used regularly, has the surface peeling off the top and sides, exposing rough wood, of concern is the ability to clean this area. A few dressers in person in care (PIC) rooms, have drawers that are difficult to open and/or close, or don't close completely.
Corrective Action(s): Ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair.
Date to be Corrected:
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: Throughout the facility it was observed that the ceiling tiles in the bedroom bathrooms are lifted (ill fitting) warped and discolored, it was described to be from the moisture from the showers.
-It was also noted that most bedrooms throughout the facility have divots in the drywall, some areas ie. behind beds, have more extensive damage from what appears to be contact with the bed frame.
-The sprinklers located in person in care (PIC) rooms, are caked with dust which may affect their use in case of an emergency. -One tub faucet in a PIC bathroom, was continuously dripping.
-An electrical panel/ breaker box located outside on the upper floor was not secured and accessible to PIC, staff stated that this box is usually locked.
-In one room the baseboard heater had a piece of metal sticking out, of concern is the potential to cause injury.
-Another bedroom had an electrical cord running from the bed area, up and through the ceiling tile, connected to the air conditioning unit in the wall.
-One bedroom window was open and missing the screen, staff checked the room and were unable to locate the screen.
-In the kitchen, it was observed that the freezer handle was broken/ falling off; and numerous kitchen cupboards were in poor repair with the door falling off the lazy Susan, cupboard handles missing, warped cupboards and damage down to the particle board, as well as a large chunk missing from the counter top making it difficult to sanitize the area.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31330 - RCR s.23(a) - A licensee must ensure that (a) no one other than a person in care smokes or uses tobacco, holds lighted tobacco, uses an e-cigarette or holds an activated e-cigarette while on the premises of a community care facility,
Observation: It was observed that there were at least 3 areas outside of the designated smoking area where tobacco products are being consumed. Two of these areas were described as staff smoking areas, where staff utilize tobacco products. It was also described that occasionally a person in care under the influence (of drugs or alcohol) will smoke in the non- designated area where staff smoke, to limit contact with other persons in care.
Corrective Action(s): Please refer to RCR s.23(2)(a) A licensee must ensure that no one other than a person in care engages in a restricted activity (smoking) while on the premise of the community care facility.
Date to be Corrected:
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 policies of the medication safety and advisory committee were not being implemented in the following areas:
-One person in care self administers 3 medications, self administration of medications is not included on their care plan, as per the requirement RCR s. 70(4)(b).
-There is no medication administration record from the pharmacy for the 3 medications that one person in care self administers, as per requirement RCR s.69(1)(b).
- There was no evidence of consent from the medical/ nurse practitioner for one person in care to self administer medications as per the requirement RCR s. 70 (4)(a).
- The PRN effectiveness was not documented on at least 53 occasions in the month of May, and at least 4 occasions in the month of June, on review of 3 person in care MARs. Documentation of effectiveness of PRN medications is required as per the MSAC policy.
Corrective Action(s): Ensure all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: June 11, 2021
CARE AND/OR SUPERVISION: 34650 - RCR s.81(3)(c)(ii) - A care plan must include all of the following: (c) a nutrition plan that (ii) specifies the nutrition to be provided to the person in care, including the requirements of any therapeutic diets.
Observation: 3 of 3 care plans reviewed had specific dietary restrictions or requirements that were reported on intake, but not included in the care plan.
Corrective Action(s): Ensure that a person in care's care plan includes a nutrition plan that specifies any nutrition requirements, and nutrition to be provided to the person in care.
Date to be Corrected:
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: 3 of 3 person in care records reviewed did not have the completed TB skin test or chest x-ray as per the screening form. At least one person in care reviewed has been in care for more than 60 days. None of the clients currently have a chest x-ray or TB skin test booked, despite it being flagged on the TB form that further testing is needed to meet the requirements.
Corrective Action(s): Ensure that all persons admitted to the community care facility comply with the Province's immunization and TB control programs.
Date to be Corrected:
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: The following was observed:
-in the client fridge, 2 food items were plated and covering in plastic wrap, however there was no date on the items. The facility reports that their practice is to discard any unlabelled food at the end of each day.
-in the pantry some food items had been removed from their original packaging placed in a clear container, and were not labelled with date opened.
- In the pantry area there was food items being stored on top of the hot water tank.
-there were what appeared to be some meat items in the freezer that were removed from their original packaging and not labelled with the date, or contents.
Corrective Action(s): Ensure all food is safely prepared, stored, served and handled.
Date to be Corrected:
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