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 following observations were noted:
- The baseboards on the 2nd floor towards the back of the east wing had black scuff marks caused by wheelchairs.
- The baseboard located on the 3rd floor measuring approximately a foot in length was missing from the wall. (CORRECTED AT THE TIME OF THE INSPECTION.)
- The 3rd floor dining area wall (near the fire extinguisher) had approximately 6-7 chips causing the inner wall to be exposed.
- The pillar to the left of the nursing station on the 3rd floor had significant amount of paint chips. Further discussion with the staff revealed this was caused by a wheelchair.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: March 28, 2022
STAFFING: 32040 - RCR s.37(1)(d) - 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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: The following observations were found during the staffing review:
- 3 of 10 staffing files found no diploma or evidence of training or skills in the physical file.
- 1 of 10 staffing files found no food safe certificate in the physical file.
Corrective Action(s): Ensure to obtain copies of any diplomas, certificates or other evidence of the person's training and skills.
Date to be Corrected: March 28, 2022
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: A review of 1 of 10 staff files found that a First aid/CPR certification was not current and had expired in August 28, 2021.
Corrective Action(s): Ensure that all staff who require a First Aid/CPR certificate is valid.
Date to be Corrected: March 28, 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: A review of the medication room found the following:
- A review of the facilities narcotic drug count sheets had inconsistencies whereby for example the second nurse signature/initials was not documented. Further discussion with leadership and a review of their narcotic drug count policy confirmed that two signatures/initials are required with every shift exchange.
- An unopened blister pack dated February 5, 2022 for a person in care was found in the medication cart. A review of the EMAR system indicated that the medications in this blister pack had been administered and confirmed sign off by the nurse. Further discussion with the leadership confirmed there are monthly audits in place to prevent further occurrences.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: March 28, 2022
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: A review of the facilities emergency supplies found pudding and crackers which had an expiration date of February 4, 2022.
Corrective Action(s): Ensure that items in the emergency kit are checked regularly for expirations dates.
Date to be Corrected: March 28, 2022
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: A review of the tub room found unlabelled shampoo and body wash on the east wing of the second floor.
Corrective Action(s): Ensure personal items of person's in care are labelled or placed in individual containers.
Date to be Corrected: March 28, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation (CORRECTED DURING INSPECTION): During the inspection of the serveries and kitchen the following were noted:
- A review of three of the servery refrigerators and freezers (including the main kitchen) found that the temperature monitoring sheets had inconsistencies and were not documented twice daily as required.
- A large tray of butter was covered but not labelled or dated.
- A small carton of milk had a best before date of January 25, 2022.
- Cottage cheese was found with an expiry date of January 24, 2022.
- A large tray of icecream was found in the freezer covered but without dates or labels.
- Jam, peanut butter, cereal and butter were placed in a container and covered, kept inside the cupboards but without any dates or labels.
Corrective Action(s): Ensure that all food is being safely stored before being served.
Date to be Corrected: March 28, 2022
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