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: Inspection of the physical facility found the following:
-the Kitchen island has the cupboard surface peeling, down to the particle board
-the bathroom has wood surfaces on the counter and cabinet with peeling and chipping paint
-the floors throughout the home had deep ruts, exposing the plywood under
of concern is the ability to keep the areas clean and sanitized due to the damage.
It was described that some of the damage may have resulted from a person who no longer resides in the home.
Additional damage was noted to the grate covering air exchange, and baseboards throughout the home appear to be damaged from repeat contact with a wheelchair.
-A drain in a bathroom sink is rusted, making the area difficult to clean and sanitize.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: Jan 31, 2023
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 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Discussion with the manager determined that performance reviews are behind schedule, and a plan will be submitted to catch up on performance reviews for all staff.
Corrective Action(s): Ensure that the performance of each employee is reviewed regularly to meet the requirement of this regulation.
Date to be Corrected: Jan 31, 2023
CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: There was no documentation available to review regarding annual dental visits or encouragement to see a dental health professional annually. Though it was described that persons in care were seeing a dental health professional regularly.
Corrective Action(s): Ensure that all persons in care are encouraged to be examined by a dental health professional at least once every year, and records are kept regarding the same.
Date to be Corrected: Jan 31, 2023
MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored.
Observation: The last documentation of the pharmacist being on site for a medication room inspection was in 2020. It was described that a med room inspection and MSAC meeting took place in January, however there was no documentation available to review from the inspection.
Corrective Action(s): Ensure that the area of the facility where medication are stored, is being inspected, and MSAC meetings are taking place and documentation is available to review from the inspection and meeting.
Date to be Corrected: Jan 31, 2023
MEDICATION: 36100 - RCR s.70(1) - A licensee must ensure that only medications that have been prescribed or ordered by a medical practitioner or nurse practitioner are administered to a person in care.
Observation: One person in care had a medication that was being used, that was not prescribed by the physician.
Corrective Action(s): Ensure all medications being administered to persons in care, have been prescribed by a medical practitioner of nurse practitioner.
Date to be Corrected: Jan 31, 2023
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Review of the four weeks of fall/winter menus found, all 4 fall/ winter menus only list one snack per day.
Corrective Action(s): Ensure that each day at least 2 nutritious snacks, with each snack containing at least 2 food groups is offered.
Date to be Corrected: Jan 31, 2023
RECORDS AND REPORTING: 39310 - RCR s.81(1) - If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: During the first day of the inspection, staff were unable to locate the care plan or documentation related to the care and supervision for 2 people in care. On day two of the inspection the care plan for one person in care was located, but it was described that there was no care plan created for a second person in care.
Corrective Action(s): Ensure that for all persons in care admitted to a care facility for more than 30 days, a comprehensive care plan is in place to guide staff in providing care to that person.
Date to be Corrected: Jan 31, 2023
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: Review of weight records for 3 persons in care, found that 2 of 3 persons in care did not have evidence of being weighed monthly, or as per their care plan.
Corrective Action(s): Ensure that all persons in care are weighed at least once each month.
Date to be Corrected: Jan 31, 2023
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