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: It was observed in 1 person in care's (PIC) shower that boxes, shoes, and other personal items are being stored on floor. The concerns is that the bathroom and shower floor would not be able to be cleaned and sanitized.
Corrective Action(s): Please ensure that items are not being stored on the bathroom and shower floor.
Date to be Corrected: October 8, 2019
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 (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: 1 out of 14 staff files reviewed did not have a current employee appraisal. The appraisal was last conducted in March 2017. The policy states that employee appraisals are to occur every 2 years. The facility says that this appraisal was complete however, there is not evidence of this.
Corrective Action(s): Please ensure that employees receive regular performance appraisals.
Date to be Corrected: October 8, 2019
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: 1 out of 2 restraint care plans had not been evaluated after 30 days as according to policy and procedures.
Corrective Action(s): Please ensure that policies and procedures are implemented by staff.
Date to be Corrected: Sept 24, 2019
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: The following was wound regarding wound care plans not being followed:
- 1 wound needed to be assessed every 2-3 days and had not been on 2 occasion.
- Another wound needed to be assessed daily and was not assessed for 2-3 days at least 5 times.
Corrective Action(s): Please ensure that care is consistent with the PICs' care plans.
Date to be Corrected: September 24, 2019
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