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: During the months of October and November the requirement for second witness for the narcotic count was completed. This requirement is written in the Medication Policy and Procedure.
Corrective Action(s): Please ensure staff follow the Policies and Procedures of the Medication Safety and Advisory Committee
Date to be Corrected: January 16, 2022
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Last Review of the Policies and Procedures was completed September 2020. Licensing was made aware the yearly review and revision is currently in process. The Medication Policy was last updated January 2021.
Corrective Action(s): Please ensure that Policies and Procedures are reviewed at least once a year and revised if necessary.
Date to be Corrected: February 4, 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: The facility practice is to allow for the PIC to make a choice to weigh themselves on a regular basis but does not ensure each PIC has a monthly weigh.
Corrective Action(s): Please ensure each PIC weight is checked monthly.
Date to be Corrected: January 31, 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 items are not recorded. Items such as fruit and snacks bars and juice is made available for the Persons in care to access. Menu should ensure that variety of food items are available at all times.
Cold/Hot Breakfast needs to include the items that are provided.
If milk is provided during meals, this should also be included in the menu.
Menu substitutions was not recorded on 7 different times during one week in August. Licensing was informed that substitutions have been implemented.
Corrective Action(s): Please ensure both the snack and meal menus provide food items that are provided.
Please ensure substitutions are recorded.
Date to be Corrected: January 28, 2022
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