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: It was noted through discussion with staff and management that there are not sufficient numbers of fall mats available for residents who require them as part of their care plan
Corrective Action(s): Ensure there are sufficient numbers of mats on site for use
Date to be Corrected: March 24
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: Inspection of the physical facility noted
- chairs throughout the facility have damaged material that is no longer cleanable
- tub room- tub bumpers coming off, tub has cracked edges (cedarhill), floor has lifted and has water under it
- curtains in room 101 are off the curtain rod
- room 18 has damaged flooring
Corrective Action(s): Ensure rooms and common areas are maintained in a good state of repair
Date to be Corrected: march 22, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Inspection of the physical facility noted a lack of cleanliness in the servery areas through put the facility. ie spilled juice and coffee in drawers, dirty and cluttered under sink cupboards, broken handles
Corrective Action(s): Ensure all common areas are maintained in a safe clean condition
Date to be Corrected: March 24,2022
STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Discussion with the management determined that employee evaluations are not up to date but a schedule has been created to ensure completion
Corrective Action(s): Ensure employee performance is reviewed regularly
Date to be Corrected: March 22, 2022
STAFFING: 32170 - RCR s.42(1)(a) - A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to (a) meet the needs of the persons in care.
Observation: It was determined through discussion with staff and managment that there are days where there are insufficient staff numbers on shift to meet the needs of the PIC's. This is for all shift times and positions
Corrective Action(s): Ensure there are sufficient number of staff for all shifts and staff types
Date to be Corrected: March 24, 2022
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: Rosewood B-wing medication cart was left unlocked and unattended while the staff left to administer the medication
Corrective Action(s): ensure that employees comply with the policies of the MSAC committee
Date to be Corrected: March 24, 2022
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: monitoring of the call bell system noted that it took over 7 min for a staff to respond to the call bell which is longer than the time accepted by the facility policies
Corrective Action(s): Ensure staff are implementing the policies and procedures of the facility
Date to be Corrected: March 24, 2022
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:
Room 14 B ADL stated PIC requires a fall mat when discussed with the RCC it was determined that the PIC no longer required it
Room 115 - the ADL/Care plan had the wrong room # on it
Corrective Action(s): Ensure care plans and ADL's reflect the needs of the PIC and are accurate
Date to be Corrected: March 24, 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: Room 111 care plan/ADL's was not reviewed within the year
Corrective Action(s): Ensure care plans are reviewed and updated yearly to reflect the needs of the PIC's
Date to be Corrected: March 24, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Inspection the physical facility noted
-shared toiletries were found in the tub rooms
-tub rooms had face clippers, combs and hair products that were shared and unlabeled
-room 111 is a shared room that has unlabeled hygiene product in the washroom
Corrective Action(s): ensure all personal hygiene items are labeled and not shared between PIC's
Date to be Corrected: March 24, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Inspection of the facility noted:
Marwood found a banana in a drawer, cups of milk and juice left out on the counter
Cedar Hill found expired chicken broth unopened and open bags of cereal unlabelled
Rosewood medication fridge had open pudding cups
Recreation fridge - unlabeled butter, open juice cups
Corrective Action(s): Ensure all food is stored appropriately
Date to be Corrected: Corrected at the time of inspection
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