PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31200 - RCR s.19(3) - If a licensee installs electronic devices for the purposes of transmitting or recording images of persons in care or members of the public, the licensee must display in a prominent place notice that electronic surveillance is being used.
Observation: CCTV cameras are recording in common areas of the facility, such as hallways, lounge, and dining rooms. There are no posted signs notifying others that electronic surveillance is occurring.
Corrective Action(s): A licensee must display in a prominent place notice that electronic surveillance is being used.
Date to be Corrected: May 20, 2022
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: Wood hand rail in 6th floor has the corner chipped exposing rough edges and a risk for splinters measuring 4cm x 2 cm, 2cm x 1cm and 1cm x 1cm.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: May 20, 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: The insulin medication has no date when it was opened, this medication has a pharmacy label that can be stored outside the fridge for 28 days. Review of 12 persons in care files found PRN medication results were not recorded for 2 persons in care. One of 12 persons in care paper MAR has missing staff signatures or codes. Two of three medication rooms has medication contingency supplies passed its expiry date. One Narcotic count sheet found two missing second staff signatures.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: May 20, 2022
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: The Licensee did not have evidence of reviewing all policies and procedures during 2021.
Corrective Action(s): Please ensure that policies and procedures are reviewed and, if necessary, revised once per year.
Date to be Corrected: May 20, 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: Staff were required to document hourly checks for persons with a restraints or at risk for falls. Staff did not document 5 hourly checks for 2 persons in care for 2 separate days. While the policy and procedure required written consent from families for tray service, staff has obtained only verbal consent for tray services from one PIC’s family
Corrective Action(s): Please ensure that policies are implemented by employees.
Date to be Corrected: May 20, 2022
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: Four out of 12 persons in care has no dental consult on file and no evidence to support encouragement.
Corrective Action(s): A licensee must encourage persons in care to be examined by a dental health care professional at least once every year.
Date to be Corrected: May 20, 2022
CARE AND/OR SUPERVISION: 34390 - RCR s.63(5) - A licensee must ensure that persons in care have sufficient time and assistance to eat safely and comfortably.
Observation: During mealtime a PIC was observed being fed by an employee who was standing. Standing while assisting with feeding does not align with safe feeding practices which minimizes the risk for choking and aspiration. This also does not ensure the comfort of the PIC while eating.
Corrective Action(s): Please ensure that persons in care have sufficient time and assistance to eat safely and comfortably.
Date to be Corrected: May 20, 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: Six of 12 persons in care has no evidence of annual nutrition assessment on file. The new Dietitian has plan of completion in place.
Corrective Action(s): A licensee must ensure that nutrition care plan or assessment is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year.
Date to be Corrected: May 20, 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: Two out of three medication rooms had PICs expired medications. These medications had been expired between 30 days to 60 days and had not been returned to the dispensing pharmacy.
Corrective Action(s): Please ensure to return person in care's medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Date to be Corrected: May 20, 2022
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