PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31330 - RCR s.23(a) - A licensee must ensure that (a) no one other than a person in care smokes while on the premises of a community care facility.
Observation: During the inspection the Licensing Officer observed one staff smoking in the area where persons in care (PIC) smoke. It was also noted that the water filtration system is located 3 feet away from the smoking area in the garage and that the water filtration tanks contain a label that states "Danger: Explosion Hazard". Discussion with the Licensee determined that one PIC does not use another outside smoking area as that would require them to go through the garage and around the building. The PIC is in a wheelchair and the other covered smoking area is not closely accessible to the living room and kitchen due to the stairs which is also in reference of RCR 14 (1) Accessibility.
Corrective Action(s): Ensure that no one other than a person in care smokes while on the premises of a community care facility.
Date to be Corrected: April 12, 2018
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 (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Review of 1 of 3 employee files found no performance review for one staff.
Corrective Action(s): Ensure that the performance of each employee is reviewed both regularly to ensure that the employee continues to meet the requirements of this regulation.
Date to be Corrected: May 3, 2018
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 (CORRECTED DURING INSPECTION): Review of 1 of 2 persons in care (PIC) care plans found 1 PIC had no record of compliance with the Province's immunization and tuberculosis control program. It was identified during the time of inspection that the PIC is not an increased risk for tuberculosis.
Corrective Action(s): Ensure that all PIC's care plan records are complete.
Date to be Corrected: CORRECTED DURING INSPECTION
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: Review of the medication found one expired topical medication that expired February 2018.
Corrective Action(s): Ensure that all expired medications are returned to the dispensing pharmacy.
Date to be Corrected: May 3, 2018
NUTRITION AND FOOD SERVICES: 37100 - RCR s.62(3) - The licensee must take all reasonable steps to ensure that the food served to persons in care follows the menu and, if unable to do so because of unforeseen circumstances, that the food provided to persons in care meets the nutritional requirements set out in subsection (2).
Observation: During inspection it was noted that the facility has a menu but it is not being followed on a daily basis as some persons in care are able to verbalize what they prefer and this does not align with what is displayed on the menu ex. spaghetti and meatballs instead of a tuna fish sandwich. It was determined that the facility does document what is being served on a daily basis in a separate book..
Corrective Action(s): Ensure that the food served to persons in care follow the menu and, if unable to do so because of unforeseen circumstance, that the food provided to person in care meets the nutritional requirements.
Date to be Corrected: May 3, 2018
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: Menu and menu documentation are completed for the current menu but it was determined that the menu was not being followed. As the menu is not being followed, it can not be confirmed that it meets the personal nutritional needs of the persons in care.
Corrective Action(s): Ensure that each person in care received adequate foods to meet their personal nutritional needs based on Canada's Food Guide and the person in care's nutrition plan.
Date to be Corrected: May 3, 2018
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