PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Upon inspection of the facility there were several areas found to be not in a clean condition and they include the following:
-the stovetop, specifically around the burners
-mold on the window frames in both the bedrooms and in the common areas
-mold on the counter caulking in the kitchen
-the bathtub in the main bathroom, although not recently used was found to have hair and other debris in it
Corrective Action(s): Please ensure all rooms and common areas are maintained in a safe and clean condition
Date to be Corrected: October 8, 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: Upon review of medication administration records, it was determined that there were 2 recent instances whereby facility employees did not comply with the policy whereby PRN medications require the administrator to assess and evaluate the efficacy of the pharmacological intervention for effectiveness.
Corrective Action(s): Ensure that all employees comply with the policies and procedure of the medication safety and advisory committee.
Date to be Corrected: October 8, 2021.
POLICIES AND PROCEDURES: 33220 - RCR s.85(1)(a) - A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Observation: It was observed that one PIC is monitored with the use of video monitoring device. Of concern is the monitoring device was on during the day and the monitor was placed on the kitchen counter in view of all persons in the home including staff, visitors and other PICs. There were no policy guidelines available to instruct staff on the appropriate use of the video monitoring device.
Corrective Action(s): Ensure there are written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of PICs.
Date to be Corrected: October 8, 2021.
CARE AND/OR SUPERVISION: 34150 - RCR s.53 - A licensee must, to the greatest extent possible while maintaining the health, safety and dignity of all persons in care, ensure respect for the personal privacy of each person in care, including the privacy of each person in care's bedroom, belongings and storage area.
Observation: Upon inspection of one PIC's bedroom, there was observed to be a reverse peep hole whereby someone is able to see into the bedroom. In discussion with the facility manager it was determined that this was in place for a previous occupant and has been on the list for some time for maintenance to remove.
Corrective Action(s): Ensure respect for the personal privacy of each PIC, including the privacy of each PIC's bedroom.
Date to be Corrected: October 8, 2021.
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: Upon inspection of the facility it was determined that the facility has not been keeping a record when menu substitutions are occurring.
Corrective Action(s): Please ensure that a record is kept of all menu substitutions.
Date to be Corrected: October 8, 2021
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Upon review of the facility's menu, there was no accompanying menu audit. Of concern is the nutritional elements have not been assessed to ensure the menu meets the nutritional needs of the persons in care (PICs) as per the Canada Food Guide.
Corrective Action(s): Ensure that records of food services and nutrition care are maintained.
Date to be Corrected: October 8, 2021
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