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: 1). 2/5 PICs' bedrooms inspected found that the window coverings do not close properly. 1/5 bedroom window covering is falling off the hooks and all bedrooms inspected window covering fixtures have concerns opening and closing them.
2). 3/5 bedrooms inspected have no closet doors. The PICs have doors for their closets.
Corrective Action(s): Please ensure all common areas are maintained in good state of repair.
Date to be Corrected: October 31, 2022
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 (CORRECTED DURING INSPECTION): 1/5 PICs charts reviewed for woundcare found that woundcare treatment flowsheets were used to track PICs skin integrity even when the PIC had no wound.
Corrective Action(s): Please ensure policies are implemented by employees and that there are systems in place to receive and update staffing records appropriately.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34210 - RCR s.54(3)(b)(iii) - A licensee must (b) assist persons in care to (iii) follow a recommendation or order for dental treatment made by a dental health care professional.
Observation: 2/7 PICs file reviews did not find any assistance provided to PICs to follow a recommendation or order for dental treatment or any documentation of the refusal of the PIC/family.
Corrective Action(s): Please ensure that assistance is provided to PICs to follow a recommendation or order for dental treatment and all refusals documented appropriately.
Date to be Corrected: October 31, 2022
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Review of 2/7 PIC's care plan found that a section of the care plan was not completed for the PICs in full.
Corrective Action(s): Please submit a plan to ensure that each care plan will be reviewed at least once every year and that all sections of the care plan will be completed in full.
Date to be Corrected: October 31, 2022
|