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: Licensing observed the damage as follows:
- Walls and poles at the entrance of the kitchen had dents, scuffs, and scratches
- The wall behind the toilet had a patch of exposed plaster from a repair attempt.
- A large patch of plaster remains unpainted in 1 PIC’s bedroom as result of repair.
- One PIC’s room had exposed drywall where baseboards had been removed throughout the room.
- One wall dent of approximately 6” x 2” in a PIC’s bedroom.
(This a repeat contravention)
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: February 28, 2022
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: For two PIC’s, written restraint agreements were not signed by the PIC, parent, representative, or closest relative.
Corrective Action(s): Please ensure restraints are used with a written agreement from PIC, parent, representative, or closest relative.
Date to be Corrected: February 14, 2022
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: For two PIC’s, written consent was not obtained from a PIC medical practitioner or nurse practitioner.
Corrective Action(s): Please ensure a restraint is use with written consent from a PIC medical practitioner of nurse practitioner
Date to be Corrected: February 14, 2022
CARE AND/OR SUPERVISION: 34630 - RCR s.81(3)(b) - A care plan must include all of the following: (b) an oral health care plan.
Observation: One PIC did not have an oral health plan.
Corrective Action(s): Please ensure care plans include oral health plans.
Date to be Corrected: February 21, 2022
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: One PIC care plan had not been reviewed for since 2020.
Corrective Action(s): Please ensure PIC care plans are reviewed and modified at least once each year.
Date to be Corrected: February 11, 2022
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: Menu audits had been completed for 1 of 4 fall/winter menus and 0 of 4 spring/summer menus. The completed audit menu identified recommended servings for 2 to 3 food groups were not being met each day (This is a repeat contravention).
Corrective Action(s): Please ensure the results of food services and nutrition care are monitored.
Date to be Corrected: February 11, 2022
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