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: An inspection of the physical facility found what appears to be water leaking from the main bathroom into an adjacent room causing damage to the drywall. It was also observed that drywall had been removed in two bathrooms in order to install new exhaust fans; however, the drywall has not yet been reinstalled. Additionally, an outside light at the back of the house was observed to be detached exposing the wires behind which requires reattachment.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: October 29, 2021.
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 medication administration records for persons in care found three instances where medications were not recorded as being administered.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: September 24, 2021
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: One person in care was observed to be using a fall mat but the use of a fall mat was not noted in the care plan of the person in care.
Corrective Action(s): Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Date to be Corrected: October 11, 2021
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: A review of the facility's menus found no evidence that the current menu had been audited to 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 nutritional plan.
Corrective Action(s): Complete menu audits to ensure that each person in care receives adequate food to meet their personal nutritional needs based on Canada's Food Guide and each person in care's nutritional plan.
Date to be Corrected: October 11, 2021
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