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: Upon inspection of the physical facility, the water temperature was measured to be above 49° Celsius at 2 out of 3 water sources that could be accessed by persons in care. The site indicated they are aware of the fluctuating water temperature in some areas within the facility and have been attempting to address this. The bathtubs on site have temperature readings that permit staff to adjust the water temperature to meet legislative requirements.
Corrective Action(s): Ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
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: Upon inspection of the physical facility, the following was observed:
- A wall in the dining room had a portion of baseboard missing and a protective wall strip from the lower portion of the wall removed
- A radiator in a common, leisure area had portion of metal that was not secured. Of concern is that a PIC may sustain a cut from the loose metal.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected:
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Upon review of the facility Policy & Procedure Manual, it was observed that the last evidence of review for several policies was in 2018.
Corrective Action(s): Please ensure that policies and procedures are reviewed and, if necessary, revised at least once each year.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: Upon review of PIC care plans, the following was observed:
- a care plan had not been updated to reflect safety checks for elopement being discontinued 1 year ago.
- 2 care plans reviewed showed daily checks for wander bracelets were not occuring.
Corrective Action(s): Ensure care plans are modified if there is a substantial change in the circumstances of the person in care.
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: Upon review of PIC care plans, the following was observed:
- 1 of 6 PICs reviewed had no record of immunizations
- 3 of 6 PICs were missing the facility portion of the record of immunization
- 2 of 6 PICs had complete records of immunization
Corrective Action(s): Ensure all persons admitted to a community care facility have documentation regarding the Province's immunization and tuberculosis control program.
Date to be Corrected:
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: REPEAT CONTRAVENTION: Upon review of the food storage in the facility kitchen, the following was observed:
- In the walk-in cooler, food was plated but not labelled with a date. Additionally, there was a carton of cream that was not labelled with a date of expiration.
- In the walk-in freezer, some food items were not labelled so as to note the contents expiry date.
- In the walk-in pantry, some food items were not labelled so as to note the contents and did not have the date on which they were opened affixed to the item.
Corrective Action(s): Ensure that all food items are labelled and dated to prevent any risk of ingesting expired food items.
Date to be Corrected:
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