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: During inspection of the physical facility it was observed that multiple doors and door frames are extensively scratched and marked. Sections of walls in the hallways were noted to have dents and scruff marks. In discussion with staff, it does not appear that a regular maintenance plan/schedule is in place for painting. Multiple tables in the dining room were observed to have missing laminate.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: April 28, 2023
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31590 - RCR s.30(b) - A licensee must ensure that all bathrooms have (b) slip resistant material on the bottom of each bathtub and shower.
Observation: Two bathroom showers (tubs) were observed without a slip resistant material on the bottom.
Corrective Action(s): Please ensure that all bathrooms have a slip resistant material on the bottom of each bathtub.
Date to be Corrected: March 22, 2023
STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: In review of staffing records, it was noted that performance reviews have not been completed as per facility policy.
Corrective Action(s): Please ensure that the performance of each employee is reviewed regularly and as required by facility policy.
Date to be Corrected: September 30, 2023
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: In review the Medication Administration Records, it was noted for a person in care that the PRN effectiveness/result is not being regularly recorded as per policy.
Corrective Action(s): Please ensure all employees comply with the medication policies and procedures.
Date to be Corrected: March 29, 2023
PROGRAM: 38010 - RCR s.55(1)(a)(i) - A licensee, other than a licensee who provides a type of care described as Hospice, must (a) provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities (i) suitable to the needs of the persons in care.
Observation: In discussion with staff regarding programming, it was noted in the 'youth section' that a planned program of activities is not currently in place. In review of the adult programming, it was noted that there is an absence of any on-going physical activities.
Corrective Action(s): Please ensure that persons in care are provided with a ongoing planned program of physical and social activities suitable to their needs.
Date to be Corrected: April 12, 2023
RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: In review of person in care (PIC) charts, 3 PIC's did not have their height and weight recorded at the time of admission.
Corrective Action(s): Please ensure that the height and weight of each person in care is recorded at the time of admission.
Date to be Corrected: March 29, 2023
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