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: The tubroom floor has water from the shower/tub pooling after each PIC's use. This was observed during the inspection of the tubroom and brought to the attention of staff.
Corrective Action(s): Please ensure that all common areas are maintained in clean and safe condition.
Date to be Corrected: November 18, 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 following was observed:
1). PRN intervention & evaluation records was not completed for 1/8 PIC on August 10.
2). Controlled Substance Inventory Record was not completed appropriately on October 11 for 1/8 PIC.
3). The med room door was propped open during the inspection. This was brought to the attention of the staff present.
Corrective Action(s): Please ensure that all employees comply with MSAC procedures and submit a plan to me as to how this will be ensured.
Date to be Corrected: November 18, 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: The following was observed:
1). Fridge temperature log in the med room was not completed consistently. In September, staff did not enter the temperature 8x for the PM and it was not completed 2x for the AM. In October, staff did not enter any temperature 11x for the PM.
2). Restraint monitoring for 1/8 PIC was not completed by staff. There was no restraint monitoring sheet in the folder for this PIC.
3). 2/8 PICs' charts had blank Moving Day Interview documents in their charts. This was brought to the attention of the staff assisting with the inspection.
4). Post fall follow ups were inconsistently completed for 1/8 PICs. Only 3 NVS were completed within the first 4 hours of an unwitnessed fall and 1x it was documented as "Sleeping" for 1 PIC.
5). 1/8 PIC's BM Record Sheet was not completed 7x in October.
6). Care worksheet for teeth/Dentures was not completed 9x for the evenings for 1/8 PICs.
Corrective Action(s): Please ensure that all polices are implemented by staff.
Date to be Corrected: November 18, 2022
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: Documentation concerning wound care was not completed 2 PICs (assessments and treatments). 1 PIC's records showed inconsistencies in the implementation of the wound care plans.
Corrective Action(s): Please ensure that care plans are implemented as required.
Date to be Corrected: November 18, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: A used comb was observed in the tub room on the clean supply cart. This was brought to the attention of the staff.
Corrective Action(s): Please ensure that items intended for personal use (to ensure health and hygiene) are not available to others.
Date to be Corrected: November 5, 2022
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