LICENSING: 30010 - RCR s.8(1) - Licensees and applicants for licences must notify a medical health officer immediately of any change in the information provided under section 7.
Observation: The following were noted:
1).CCFL was unaware that the manager of the facility had changed and that prior to this manager, a manager had been appointed to the position without notification to CCFL.
2). The name of the facility has been changed without any notification to Licensing.
Corrective Action(s): Please ensure that a notification is sent immediately to Licensing of any change in information on the Licence.
Date to be Corrected: Feb 26, 2021
LICENSING: 30040 - RCR s.8(2)(b) - A licensee must not make any structural change to a community care facility unless the licensee (b) receives written approval from the medical health officer.
Observation: During the physical facility inspection on January 27th 2021, Licensing was informed that a total of 5 multi-bed bedrooms were completely painted and renovation work on the roof of the building was completed. There were a total of 33 PICs in care during this time.
Corrective Action(s): Please ensure that a health and safety plan is submitted to and approved by Licensing prior to any significant construction/renovation work at the facility.
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: The baseboard heat cover has fallen off the heater in the exit hallway leading to the basement loading area. A piece of wood has been used to cover the heating pipes.
Corrective Action(s): Ensure all common area and hallways including baseboard heaters are maintained in a good state of repair.
Date to be Corrected: February 26th, 2021.
STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person.
Observation: Review of 10 staff files found that 1 staff did not have a current criminal record check.
Corrective Action(s): Ensure that all staff have current criminal record check as per facility policy.
Date to be Corrected: February 26th, 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: Medication records (MAR) for 3 out of 5 PIC’s did not have the effectiveness of PRN medication noted after the PRN was administered.
Corrective Action(s): Please ensure that staff follow the guidelines, policy and procedures of the MSAC.
Date to be Corrected: February 26th, 2021
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 were observed:
1). Neurovital assessments were incomplete in 3 out of 5 PIC’s vital signs flowsheets and 2/5 files that documented a fall.
2). The daily flowsheet documentation regarding Activities of Daily Living (ADL) was completed inconsistently and blank spaces were noted for certain days in 5 out of 5 PIC’s files.
3).The admission checklist had missing signatures, admission dates, and nursing assessments for 4 of 5 PIC files reviewed
Corrective Action(s): Ensure that staff follow and implement the policy and procedures of the facility.
Date to be Corrected: May 5th, 2021
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: 3/5 recreation activity care plans were dated from 2015, 2017 and 2018 which evidenced that a review was not completed yearly. 1/5 recreation care plan did not have the date of the care plan or the review date.
Corrective Action(s): Ensure that all documents in the PIC's care plan are reviewed and updated if required at least once per year
Date to be Corrected: May 7th, 2021
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: Inspection of the tub/spa rooms determined that personal items were being left in the tub/spa rooms and were not labelled with individual person in care (PIC) names. There were some personal items labelled with PIC's names also found in this room.
Corrective Action(s): Ensure that staff assist PICs in maintaining health, hygiene and remove PIC's personal items from common tub/spa right after use.
Date to be Corrected: February 26th, 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: Licensing was unable to determine if fridge and freezer temperatures were being monitored in the kitchen storage supply room and the resident fridge in the office area to ensure that all food is safely stored as there were no temperature logs for a fridge and a freezer.
Corrective Action(s): Please ensure that employees monitor the fridge and freezer temperatures and document it appropriately.
Date to be Corrected: February 26th, 2021
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: 4/5 PICs did not have the consent for emergency care form completed. As per the Manager, the facility is the process of getting this consent for the new admissions.
Corrective Action(s): Ensure that all PIC’s have written consent for emergency treatment.
Date to be Corrected: May 7th, 2021
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