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: It was observed in common areas throughout the facility, doors and wallls that have deep scuffs requiring repair and paint. Also noted in the main floor lounge area were window blinds that are broken. As noted in the previous inspection from October 2019, flooring requires replacement. According to the facility manager this renovation had been put on hold due to the pandemic.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: January 25, 2021
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: It was identified during an incident that occurred at the facility that a care plan had not been updated to reflect that the PIC was exhibiting aggressive behaviours. Due to his aggressive behaviours the PIC required 2 staff to provide care, and this did not occur
Corrective Action(s): Ensure that the care plan is revised when there is a substantial change in the circumstances of the PIC.
Date to be Corrected: January 25, 2021
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: It has been observed that reportable incidents have not been reported in a manner required. The reports have been late, incomplete, reported incorrectly, and have required a significant amount of follow up. It should be noted that the facility has been on outbreak for the past 2 months, and allowances for timeliness have be made during that period.
Corrective Action(s): Ensure reportable incidents are reported in a manner required by the medical health officer
Date to be Corrected: January 25, 2021.
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