LICENSING: 30030 - RCR s.8(2)(a)(ii) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (ii) a description of how the licensee intends to ensure the health and safety of persons in care while the change is being made.
Observation: Hallway floor upgrade was completed in second floor but no submission and approval from Licensing of PICs health and safety plan.
Corrective Action(s): A licensee must not make any structural change to a community care facility unless the licensee first submits to a medical officer a description of how the licensee intends to ensure the health and safety of persons in care while the change is being made.
Date to be Corrected: June 22, 2022
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: Furniture in the PICs bathing room has edges chipped exposing the wood particles. A PIC's personal bedroom table requires repair, its surface has 30% peeled and chipped. A dresser had a top drawer that would not close and protruded.
Corrective Action(s): Staff must ensure that all furniture and equipment used by persons in care are maintained in a good state for repair.
Date to be Corrected: June 22, 2022
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: A licensee's policy and procedure that staff performance review are completed annually. Seven of 9 staff had their last performance review completed in 2019.
Corrective Action(s): A staff performance review must be completed according to the licensee's policies and procedures.
Date to be Corrected: August 31, 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 insulin medication has no date when it was opened, this medication has a pharmacy label that can be stored outside of the fridge for 28 days. Medication refrigerator temperature was not recorded 19 times in May 2022, temperature has to be monitored twice daily.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: June 22, 2022
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: Two of 6 PICs has no evidence of compliance to Province's immunization and tuberculosis control program.
Corrective Action(s): A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: June 22, 2022
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