LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: Facility does not have evidence of an adequate system to monitor the nutrition provided to persons in care (PIC)
Corrective Action(s): Please ensure you have evidence of the regular monitoring of the nutrition system.
Date to be Corrected: February 24, 2020
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: Medications are stored in a manner that could be accessible to persons in care (PIC) and others in the home.
Corrective Action(s): Please ensure that all medications are stored in a manner that is inaccessible to PIC, such as in a locked room or cabinet where the keys or other means to the medications are inaccessible as well.
Date to be Corrected: February 24, 2020
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: Two of the thirteen policies examined had not been reviewed in the past year.
Corrective Action(s): Please ensure that all policies are reviewed at least once each year.
Date to be Corrected: February 24, 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: The Nutritional care plan for one person in care (PIC) has not been modified to meet the needs of the PIC in the past 1 year.
Corrective Action(s): Please ensure the Nutritional care plan is revised to meet the PIC needs.
Date to be Corrected: February 24, 2020
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Two food items found in the kitchen were past their expiration date.
Corrective Action(s): Please ensure that expired food items are not served to persons in care.
Date to be Corrected: February 24, 2020
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: One person in care does not receive two nutritious snacks per day as required.
Corrective Action(s): Please ensure that all persons in care receive two nutritious snacks each day.
Date to be Corrected: February 24, 2020
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: A review of records for two persons in care show that weight has not been monitored for the past two months.
Corrective Action(s): Please ensure that all persons in care are weighed monthly.
Date to be Corrected: February 24, 2020
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