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 dry wall in the living area across the laundry room has two holes measures 8 x 3 inches. One person in care's room dry wall behind the shoe rack has a hole measures 2 x 2 inches. The kitchen drawers has no proper support underneath when opening them. Few kitchen cabinet doors won't close completely. The kitchen cabinet inside surfaces has visible discoloration and chips. The wall beside the dishwasher has water leak damage as evidenced by discoloration.
Corrective Action(s): A licensee must ensure that all rooms and commons areas are maintained in good state of repair.
Date to be Corrected: November 31, 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: PRN medication results were not recorded to 3 persons in care.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: October 31, 2022
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: No emergency menu was provided by staff during inspection.
Corrective Action(s): A licensee must have an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuations of persons in care.
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: Two of 3 persons in care's care plan was not reviewed in 2021.
Corrective Action(s): Please ensure that each care is reviewed and, if necessary, modified at least once each year.
Date to be Corrected: October 31, 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): Four tetra packs of broth past their best before dates were stored in the food storage cabinet.
Corrective Action(s): Please ensure that all food is safely stored.
Date to be Corrected: October 14, 2022
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: Four person in care's medications were found passed its expiry date.
Corrective Action(s): Please ensure to return the person in care's medication to the dispensing pharmacy if the expiry date on the medication has passed.
Date to be Corrected: October 31, 2022
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(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: Three of 3 persons in care did not have the weight taken monthly for 2021 and 2022.
Corrective Action(s): Please ensure that the each person in care is weighed at least once each month.
Date to be Corrected: October 31, 2022
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