PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31240 - RCR s.21(a) - A licensee must ensure that all furniture and equipment for use by persons in care (a) meet the needs of the persons in care.
Observation: A person in care is unable to safely access all common areas of the facility as they do not have the equipment required to meet their specific needs.
Corrective Action(s): Please ensure the PIC has all the equipment required to meet their needs..
Date to be Corrected: Immediately
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: -The personal hygiene equipment of PICs that should not be shared, such as razors, clippers and brushes were stored unlabelled in the bathroom.
-Two stereos were found on the floor beside a bathtub directly below a counter with a sink. One of the stereos was plugged into the electrical socket and the floor beside the bathtub was wet with water.
-Medical equipment for a PIC was found stored on the carpeted floor beside their bed and inside their closet. Of concern is the ability to ensure both the carpet and the equipment are kept clean and hygienic.
- One shower contained a shower chair, however there was no slip resistant surface below it to reduce the risk of falls for PICs.
Corrective Action(s): Please ensure there is are systems in place so that equipment used by persons in care is maintained in a safe and clean condition.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Chemical cleaning supplies and other potential hazards were found accessible to PICs under the kitchen sink and in the laundry room.
Corrective Action(s): Ensure that any and all hazardous materials are securely stored.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: One medication was found unsecured in a drawer in a bathroom.
Corrective Action(s): Please ensure all medications are stored securely as required.
Date to be Corrected:
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: Policies and procedures were reviewed and it was determined that some policies provided direction to staff that was inconsistent when compared and/or contained information that was out of date. There was no evidence a review had been completed in the previous 12 months.
Corrective Action(s): Policies and procedures must be reviewed at least once each year and revised as needed.
Date to be Corrected:
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: The Licensee's policy requires staff to maintain a record of the financial disbursements made on behalf of persons in care, ensure receipts are retained and reconcile the PICs account each month.
After reviewing the financial records for all PICs, it was confirmed staff did not implement the policy when they did not maintain and reconcile the records each month or retain receipts for all purchases made.
Corrective Action(s): Please ensure staff implement the policies and procedures of the licensee.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34150 - RCR s.53(1) - A licensee must, to the greatest extent possible while maintaining the health, safety and dignity of all persons in care, ensure respect for the personal privacy of each person in care, including the privacy of each person in care's bedroom, belongings and storage area.
Observation: - Staff were observed providing a PIC with personal care in a common area of the home which did not ensure privacy or dignity.
- Personal items and equipment that do not belong to a PIC are being stored the PICs private bedroom.
Corrective Action(s): Please ensure that a person in cares dignity and privacy is respected at all times.
Date to be Corrected: Immediately
CARE AND/OR SUPERVISION: 34530 - RCR s.74(2)(b) - A licensee must ensure that a person in care is not restrained (b) for the convenience of employees.
Observation: Documentation confirmed that on at least one occasion in the last month, staff restrained a person in care for convenience.
Corrective Action(s): Please ensure restraints are not used for the convenience of the staff
Date to be Corrected: Immediately.
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: One PIC who had experienced a change in their care needs had a care plan that had not been updated to reflect those changes and was documented as being reviewed more that 12 month before.
Corrective Action(s): Please ensure that care plans are reviewed and updated as required.
Date to be Corrected:
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: One unlabeled medication was found that had not been packaged by the pharmacy.
Corrective Action(s): Please ensure all medications are packaged by the pharmacy
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37100 - RCR s.62(3) - The licensee must take all reasonable steps to ensure that the food served to persons in care follows the menu and, if unable to do so because of unforeseen circumstances, that the food provided to persons in care meets the nutritional requirements set out in subsection 62(2).
Observation: The menu substitution record confirmed leftovers as the documented reason for 50% of the substitutions.
Corrective Action(s): Please ensure the food provided follows the menu unless due to unforeseen circumstances.
Date to be Corrected:
RECORDS AND REPORTING: 39230 - RCR s.79(1)(a) - A licensee must keep a record in respect of each person in care showing the following information: (a) all money, valuables and other things held by the licensee in trust or safekeeping for persons in care.
Observation: The personal finances of all persons in care were reviewed and it was determined that not all funds were included in their records.
Corrective Action(s): A record of all funds held in safekeeping, including gift cards, must be maintained.
Date to be Corrected:
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: One person in care is not being weighed as required.
Corrective Action(s): Please ensure each person in care is weighed as required.
Date to be Corrected: Immediately
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: The Licensees nutrition monitoring system could not be reviewed in its entirety as half of the audit that is to be completed for each of the 4 week menus had not been retained.
Corrective Action(s): Please ensure to keep the records respecting the monitoring of nutrition.
Date to be Corrected:
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