PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31050 - RCR s.15(1) - A licensee must ensure that, if necessary for the health and safety of a person in care, windows are secured in a manner that prevents a person in care from falling from, or exiting through, the window.
Observation: A window at the end of a hallway on the second floor is at a lower height and has a ledge that provides a place to sit. This window does not have a screen in place and opens outwards wide enough for an adult to fit through. The window is difficult to latch when closed, making it unsecured.
Corrective Action(s): Please ensure that this window is secured so that persons in care are prevented from falling from the window.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Water accessible to PIC in the dining area was observed to be 53 degrees Celsius when measured.
Corrective Action(s): Please ensure that all water accessible to persons in care is not more than 49 degrees Celsius.
Date to be Corrected:
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: -The surface of the weight bench located in the gym was ripped and of concern is the ability to clean it. A weight rack with weighted balls stored on it was unsteady and could fall if bumped into.
-A dresser provided to a PIC by the licensee had a drawer that would not fully close.
-Two chairs in the second floor TV lounge had rips on the seats of the chairs and of concern is the ability to clean them.
Corrective Action(s): Please ensure that all furniture and equipment is maintained in a good state of repair.
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: -A bathroom wall heater in one person in cares room has had the cover removed, exposing sharp pieces of metal which could cause injury to persons in care.
-The screen in one bedroom window is broken and the window frame is bent, making it difficult to secure the window closed. The window covering in another bedroom is broken and unable to be used. In a third bedroom, the handle to the window has been broken off, making it difficult to secure closed, and in a fourth bedroom, a broken handle causes the window to be unable to be opened if needed. Two bedrooms have had windows removed completely from their frames and have not yet been replaced, one of the two windows fell out of the frame, to the ground below due to reported damage.
-The walls in one bedroom has scrapes that have removed the paint and exposed the dry-wall underneath, making it difficult to keep clean.
-The carpet in the second floor TV lounge has holes worn through, exposing the floor beneath.
-Two fire-doors were observed not to close properly, one of the two had a sharp piece of plating that was bent outward and of concern was the risk of injury.
-The counter top and sink surround in one janitor closet had water damage noted causing the wood to swell and the caulking to peel.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected:
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: -One bedroom belonging to a person in care had numerous personal items such as clothing stored on the floor, and in the games room, games are stored on the ground as no shelving is provided, of concern is the ability to clean the floors.
-One hatchet was found on the bedside table of a person in care, this is an item that, as per the licensee, is not permitted.
-Bedrooms, bathrooms, the gym and stairwell floors were noted to have a build-up of dirt and dust. Pieces of garbage were also found in these areas left of the floor.
-Bathrooms in the common areas as well as bathrooms in PIC rooms had counter-tops, sinks, toilets and showers that were noted to be dirty. Some showers had a build up of soap scum on the floor and walls.
-Window sills in the bedrooms were dirty and the windows in the stairwells had dust and cob-webs on them.
-Three janitor closets had dirty floors, counters and sinks.
-Two laundry rooms floors were dirty and had garbage on them.
-The second floor TV lounge carpets is stained in more than one area. Garbage was found on the floor.
-Cigarette butts found outside a side door, littering the ground, this is a nonsmoking area.
-Staff report that persons in care are required to complete the cleaning in the facility unless it is deemed unsafe or the PIC requires assistance. There is no formal process in place to ensure that cleaning is occurring on a regular basis.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a clean and safe condition.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31450 - RCR s.26(3) - If requested by a person in care, and unless it would be unsuitable given the health and safety needs of the person in care, a licensee must ensure that the entrance to the bedroom of the person in care can be locked from the inside.
Observation: All of the six bedrooms inspected do not have the ability to lock the door from inside, in addition, the 4 bedrooms that have shared bathrooms, do not provide a locked door that could prevent a person from accessing the bedroom from the bathroom. It was confirmed by staff that persons in care are not permitted to lock their doors, even if there has been no risk identified on admission, or during their stay at the facility.
Corrective Action(s): Please ensure that each bedroom has the ability to be locked from the inside, this would include bathroom doors, unless it has been deemed unsuitable given the health and/or safety needs for the person in care.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31550 - RCR s.29(1)(a) - A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including (a) a safe, secure place in which the person in care may store valuable property.
Observation: Of the six, double occupancy rooms that were inspected, none provided persons in care with a safe, secure place to store valuables. It was confirmed with staff that persons in care were not permitted to keep valuables in their possession, however could store items with staff and access them during office hours only.
Corrective Action(s): Please ensure that all persons in care are provided, in their bedrooms, with a safe, secure place to store valuable.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: Both of the two laundry rooms do not have slip resistant floor surface. Persons in care do some of their own laundry.
Corrective Action(s): Please ensure that the laundry rooms have a slip resistant floor surface.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: Medication was observed to be unsecured sitting on the front administration desk and in the inter-facility staff mail box in the administration office.
Corrective Action(s): Please ensure that all medications are safely and securely stored.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31870 - RCR s.69(3)(b)(i) - A licensee must ensure that (b) in the case of a person in care whose short term care plan or care plan provides for the person in care to self-administer medication, the person in care (i) has a safe and secure storage area for medication.
Observation: Two persons in care who self administer some of their own medication, have not been provided with a safe and secure storage area for their medication and so leave it on their bedside table in their double occupancy room.
Corrective Action(s): Please ensure that for persons in care who are permitted to self-administer medication, that they are provided with a safe and secure storage area for their medication.
Date to be Corrected:
POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation: In a review of the emergency supplies the following was noted:
-There was an insufficient amount of food and water for all 62 persons in care and including staff.
-The only two food items available were both expired, one in 2018 and the second in 2020. The powdered milk expired in 2019 and only 90L of water was available.
-The first aid supplies were wet and contained medication that expired in 1998.
-No previsions were provided to heat or serve the food, such as bowls/plates and utensils.
-24 blankets were provided, however no other means for warmth or shelter.
-The emergency supply storage closet had other items stored in front of it making it difficult to fully open and access. No means of transporting the emergency items was provided and it was noted that the items were heavy and would be difficult to move in the event of an emergency.
Corrective Action(s): Please ensure there is a plan in place to continue to provide care in the event of an emergency.
Date to be Corrected:
POLICIES AND PROCEDURES: 33220 - RCR s.85(1)(a) - A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Observation: A review of policies determined that there is no policy in place to guide staff related to:
- The restricted use of the telephone for persons in care while at the facility.
-The use of electronic surveillance as RCR s.85(2)(a.1)(i)
- The monitoring of the nutrition of a person in care as per RCR s.85(2)(g)
Corrective Action(s): Please ensure that there is a written policy to guide staff in all matters related to the care and supervision of persons in care.
Date to be Corrected:
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: - Chemicals and cleaning supplies are stored in janitor closets, however those doors were observed being left unsecured. During the inspection it was also noted that PIC were being permitted to keep chemical cleaners in their rooms and bathrooms. Staff confirmed that chemical items were not being stored securely, however a review of facility policy determined that PIC are not to have chemical cleaners in rooms or bathrooms, and all chemicals must be secured in assigned areas.
-A review of the policy to guide staff in the storage of left over food determined that staff are required to cover, label and date all food. During the inspection of the kitchen it was noted that food was not being dated prior to being stored, a sticker system with the day of the week is utilized, however it does not include the actual date the item is being stored. Dry goods that are removed from their original container and stored in the supply closet were stored without a label or date on the container.
-A review of the Medication Administration Records for four persons in care showed that two persons in care who were administered PRN medications did not have the effect of those medications documented as per the facility policy.
Corrective Action(s): Please ensure that all employees implement the policies.
Date to be Corrected:
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 records for 4 persons in care showed that one person in care did not have a completed immunization and TB screening form.
Corrective Action(s): Please ensure that all persons admitted comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected:
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: Supervising pharmacist last inspected the medication storage area(s) in June of 2021. Inspection is now past due.
Corrective Action(s): Please ensure that the supervising pharmacist inspects the medication storage area(s) as required.
Date to be Corrected:
MEDICATION: 36080 - RCR s.69(1)(b) - A licensee must ensure that a pharmacist (b) records all medications on the person in care's medication administration record.
Observation: In a review of the Medication Administration Record (MAR) for 4 persons in care demonstrated that one person in care had two medications that were hand-written on their MAR, staff were unable to confirm who wrote the medication on the record for the person in care.
Corrective Action(s): Please ensure that only a pharmacist records the medications on the PIC MAR.
Date to be Corrected:
MEDICATION: 36100 - RCR s.70(1) - A licensee must ensure that only medications that have been prescribed or ordered by a medical practitioner or nurse practitioner are administered to a person in care.
Observation: In a review of the Medication Administration Records for four persons in care, it was observed that medication that was not prescribed to them was being administered by staff and documented on the record. These medications were medications that were listed on the Standing Order records. It was confirmed with staff that no persons in care currently have Standing Order medications that have been prescribed by a physician, however staff were continuing to administer without an order.
Corrective Action(s): Please ensure that no medications are administered without a physicians order.
Date to be Corrected:
MEDICATION: 36140 - RCR s.70(4)(b) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (b) included in the care plan of the person in care.
Observation: One person in care who self-administers two medication did not have it included in their care plan.
Corrective Action(s): Please ensure that if a person in care self-administers medication, that it is included in their care plan.
Date to be Corrected:
MEDICATION: 36160 - RCR s.72(a) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (a) the person in care is no longer taking the medication.
Observation: A blister pack of medication belonging to a person in care who had been discharged more than 30 days prior was found in the medication storage area and had not been returned to pharmacy as required.
Corrective Action(s): Please ensure that medication that is no longer required is returned to pharmacy.
Date to be Corrected:
RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: A review of records for four persons in care determined that weight and height was not recorded upon admission. Staff confirmed that weight and height is not collected for any persons in care upon admission.
Corrective Action(s): Please ensure that upon admission, height and weight of persons in care is recorded.
Date to be Corrected:
RECORDS AND REPORTING: 39050 - RCR s.71(b)(ii) - A licensee must ensure that (b) if changes in the directions for use of a medication are made by a medical practitioner or nurse practitioner, (ii) the dispensing pharmacy is promptly notified.
Observation: One person in care had a medication that was discontinued by the prescribing physician, however there was no evidence that the pharmacy had been notified and the medication was still documented on the medication administration record.
Corrective Action(s): Please ensure that if there are changes in the direction for the use a medication, the pharmacy is notified promptly.
Date to be Corrected:
RECORDS AND REPORTING: 39190 - RCR s.78(2)(a) - A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care.
Observation: Medication Administration Records for four persons in care were reviewed.
-One person in cares record contained only 1 of 2 pages required.
-Three persons in care had medications that were being administered by staff, however their records were incomplete.
-One person in care medication record had "error" written beside some of their medications, however their was no documentation as to what that error was.
-One person has a medication that is being administered each morning that is not on the medication administration record, however is ordered by the physician.
-Three persons in care had medications that they self-administer, however there record has not been completed with the amount administered.
-One person in cares medication record had been resent by the pharmacy due to changes to the medication, this was not places in the records binder as so staff were not administering or documenting as per the most recent physicians orders,
Corrective Action(s): Please ensure a record is maintained off all medication administered to persons in care.
Date to be Corrected:
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: A review of records for four persons in care showed that monthly weights are not completed. Staff confirmed that persons in care are not weighed monthly
Corrective Action(s): Please ensure that all persons in care are weighed a least once each month.
Date to be Corrected:
|