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 of the physical facility, the following was observed in Building # 1:
1) The face plates for the baseboard heater at the front entrance, for the baseboard heater in the back stairwell heading to the second floor, and for the baseboard heater in the bathroom on the third floor were detached exposing sharp coils behind and require reattachment.
2) The closet door in the downstairs bathroom was removed and leaning up against the wall and requires reinstallation.
3) A window screen was duct taped to a first floor bedroom window which makes removing the screen in the event of an emergency difficult.
4) One fire door's electronic lock mechanism was pulled away from the wall and requires reattachment in order to prevent malfunction.
In Building # 2, the faucet in the second floor kitchen was loose and moved when it was turned on and requires tightening to prevent potential leakage.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: October 29, 2021
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: An inspection of the facility's dining room found two places where the linoleum on the floor is buckled and pealing which makes it difficult to keep clean and poses a potential tripping hazard. Additionally, it was observed that a strip of paving stones (approximately 60 cm in length) along the south side of building # 2 are loose and separated posing a potential tripping hazard.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: October 15, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: The storage room in Building # 1, where cleaning agents and chemical products are stored, was observed to be unlocked with its door propped opened.
Corrective Action(s): Ensure that cleaning agents, chemical products, and other hazardous materials are safely and securely stored.
Date to be Corrected: September 17, 2021
STAFFING: 32020 - RCR s.37(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (b) character references in respect of the person.
Observation: A review of staff files found that for two employees only one character reference had been obtained for each.
Corrective Action(s): Ensure that no person is employed unless the manager has obtained at least two character references in respect of the person.
Date to be Corrected:
STAFFING: 32040 - RCR s.37(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: A review of staff files found two staff had expired first aid certificates (one expired in January 2019 and the other in April 2020) and one staff with an expired Food Safe certificate (it expired in October 2019).
Corrective Action(s): Ensure that copies of any diplomas, certificates, and other evidence of employee training and skills is obtained from employees.
Date to be Corrected: October 29, 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: A review of medication administration records for persons in care found two instances where medications were not recorded as being administered.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: September 16, 2021
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: The facility's emergency plan did not include any food or water to sustain persons in care and staff for 72 hours in the event of an emergency.
Corrective Action(s): Ensure that an emergency plan sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Date to be Corrected: October 1, 2021
CARE AND/OR SUPERVISION: 34170 - RCR s.54(2)(b) - A licensee must (b) ensure that a medical practitioner or nurse practitioner can be contacted in an emergency.
Observation: A review of person in care admission records found that for three persons in care there was no record of a medical practitioner's or nurse practitioner's contact information in the event of an emergency. Management relayed that all persons in care are seen by the facility's physician; however, as the facility's physician had recently changed, her phone number had not yet been recorded.
Corrective Action(s): Ensure that a medical practitioner or nurse practitioner can be contacted in an emergency.
Date to be Corrected: September 17, 2021
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: A review of person in care admission records found no evidence of results for tuberculosis skin tests where tuberculosis screening indicated that skin tests were necessary.
Corrective Action(s): Ensure that all persons admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: October 29, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation (CORRECTED DURING INSPECTION): An inspection of the facility's kitchen found three open items in the freezer which were not labelled or dated and one rotten watermelon in the fridge. There were also five opened items in a fridge designated for persons in care which were not labelled or dated.
Corrective Action(s): Ensure that all food is safely prepared, stored, served, and handled.
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: A review of the facility's menus found that the current menu had not been audited to ensure that each person in care receives adequate food to meet their personal nutritional needs based on Canada's Food Guide and the person in care's nutritional plan.
Corrective Action(s): Ensure that menu audits are completed to ensure that each person in care receives adequate food to meet their personal nutritional needs based on Canada's Food Guide and each person in care's nutritional plan.
Date to be Corrected: October 1, 2021
RECORDS AND REPORTING: 39490 - RCR s.88(a) - A licensee must keep a record of all of the following: (a) minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents.
Observation: During the inspection it was observed (and confirmed by facility management) that the facility does not keep a record of incidents involving persons in care which are not reportable.
Corrective Action(s): Ensure that a record is kept of all minor accidents, illnesses, and medication errors involving persons in care that do not require medical attention and which are not reportable incidents.
Date to be Corrected: October 1, 2021
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