PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: Inspection of the facility determined that the emergency equipment (ex. fire extinguishers, emergency lighting) was last inspected on March 8, 2018.
Corrective Action(s): Ensure that all emergency equipment is inspected on a regular basis.
Date to be Corrected: July 11, 2018
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 1 of 4 care plans for persons in care (PIC) determined that it was last reviewed on March 27, 2018. Discussion with the facility Manager determined that they had recently been completed but still are to be placed in the care plan binder.
Corrective Action(s): Ensure that care plans are reviewed at least once per year.
Date to be Corrected: July 11, 2018
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Review of 1 of 4 person in care (PIC) care plans found that the immunization documentation was started but not completed.
Corrective Action(s): Ensure that each PIC's care plan records are complete.
Date to be Corrected: July 11, 2018
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (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: Review of 1 of 4 person in care (PIC) care plans found that there was no weights documented for January and April 2018.
Corrective Action(s): Ensure that monthly weights are obtained for each PIC.
Date to be Corrected: July 11, 2018
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: Review of the food service documentation and discussion with staff determined that the facility does not document menu substitutions. Discussion with staff confirmed that items substituted are from the same food group as outlined by the Canada Food Guide and individual food substitutions are documented individually in the daily care plan documents.
Corrective Action(s): Ensure that menu substitutions are recorded.
Date to be Corrected: July 11, 2018
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