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: In discussion with the facility manager, it was confirmed that the MSAC has not convened since May 2020.
The MSAC is required to establish and review; employee medication training and orientation, medication policies and procedures, medication errors and adverse reactions as well as ensuring compliance from employees.
Corrective Action(s): Please ensure routine MSAC meetings occur as required.
Date to be Corrected: November 23, 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: During the inspection it was noted that the walls, doors and doorframes in the common areas as well as bedrooms have multiple scratches and paint chipped off, some exposing the dry-wall. One bedroom had multiple holes in one wall. In discussion with the manager, the condition of the walls and doors was partially contributed to the mobility devices used by those in care.
In one bedroom the metal air in-take cover was bent outward, of concern is the potential for injury.
This is a repeat contravention from AKUR-BYQM93 dated March 1, 2021
Corrective Action(s): Please ensure that all common areas are maintained in a good state of repair.
Date to be Corrected: November 23, 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: In a review of medication records (MAR) for persons in care, it was observed on two PICs records that PRN medication results were documented inappropriately as "given" instead of their outcome.
This is a repeat contravention from AKUR-BYQM93 dated March 1, 2021
Corrective Action(s): Please ensure that all employees comply with policies and procedures.
Date to be Corrected: November 23, 2021
MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored.
Observation: It was confirmed in discussion with the manager that the Medication storage room has not been inspected by the supervising pharmacist in 18 months
Corrective Action(s): The supervising pharmacist must inspect areas where medications are stored.
Date to be Corrected: November 23, 2021
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: When asked, the facility manager was unable to provide evidence of current menu audits.
Corrective Action(s): Please ensure there is monitoring of the food services and nutrition care.
Date to be Corrected: November 23, 2021
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