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: Melamine laminate on the edge of kitchen counter adjacent to the cooking range has peeled off impeding proper cleaning and disinfecting.
Corrective Action(s): Please ensure that the kitchen counter top is maintained in good state of repair.
Date to be Corrected: February 14, 2020
STAFFING: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: Upon review of 3 employee files it was noted that no employee appraisals was entered in the computer system for 2019.
Corrective Action(s): Please ensure the employee appraisals are completed and recorded as per facility policy.
Date to be Corrected: February 14, 2020
STAFFING: 32340 - RCR s.70(2)(b) - A licensee must ensure that employees who store, handle or administer medication to persons in care (b) have successfully completed any training programs established by the medication safety and advisory committee
Observation: Upon inspection of medications it was noted that 1 PIC's (person in care) 3 medicated PRN compounds had no expiry dates on the containers.
Corrective Action(s): Please ensure that staff complete the proper medication safety checks (Rights of Medication Administration) before administering the medications.
Date to be Corrected: February 14, 2020
CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: Upon inspection of 3 PIC files, it was noted that 1 PIC who was admitted in August, 2019 still does not have a activity/recreation plan.
Corrective Action(s): Please ensure that PIC have a documented recreation care plan in place which is reviewed annually. As per Manager, this was being done by a staff.
Date to be Corrected: February 14, 2020.
CARE AND/OR SUPERVISION: 34690 - RCR s.81(3)(e)(iii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (iii) a plan for following up on any falls suffered by a person in care.
Observation: Review of 2 PIC files who had fall last year found that 1 PIC still does not have documented follow up care plan post fall.
Corrective Action(s): Please ensure that all PIC with falls risk have updated follow up care plans in place.
Date to be Corrected: February 14, 2020
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: Review of 3 PIC care plans found 1 PIC care plan that was revised in 2018 had no review done for last year.
Corrective Action(s): Please ensure that all PIC care plans are reviewed annually.
Date to be Corrected: February 14, 2020
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