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: The following was observed: reading room wall area and unit dining room wall as well as corner outside of a person in care's room had different sizes of wear and tear with plaster being exposed.
Corrective Action(s): Please ensure that all of the common areas are in a good state of repair.
Date to be Corrected: February 28, 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: The facility's Weight Record Policy regarding reweighing a person in care if significant weight change is noted was not followed.
Corrective Action(s): Please ensure staff follow the Policies and Procedures
Date to be Corrected: February 28, 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: Of the 9 files reviewed, one is missing their yearly review
Corrective Action(s): Please ensure that each care plan is
Date to be Corrected: February 28, 2022
CARE AND/OR SUPERVISION: 34890 - RCR s.83(4)(b) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (b) immediately seek the advice of a health care provider if the person in care has experienced, unintentionally, a significant change in weight,
Observation: The Monthly Weight Report indicates there were 13 times a PIC recorded a significant change in weight without a follow up by a health care provider.
Corrective Action(s): Please ensure that there is a follow up if the person in care experiences a signifcant change in weight. If the recorded weight is incorrect, a system must be in place to ensure the correct weight is recorded.
Date to be Corrected: February 14, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Out of the 9 files reviewed, 3 of the person in care are missing their compliance with the immunization and TB control.
Corrective Action(s): Please ensure all records are complete
Date to be Corrected: February 28, 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: Monthly Weight Report was provided and 5 Persons in Care were missing one monthly weight, while another PIC has no monthly weights recorded for the year.
Corrective Action(s): Please ensure each person in care is weighed at least once a month.
Date to be Corrected: February 28, 2022
RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: Snack Menu is listed as Assorted Homebaked Goods and Fruit Tray. The facility does not maintain a record of daily or weekly snack items.
Corrective Action(s): Please ensure snack menu is recorded ensuring there is a variety of choices made available to the persons in care.
Date to be Corrected: February 18, 2022
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