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: During the inspection of the physical facility the following was noted:
- A transition strip between a shower and the floor had been removed due to damage and not replaced.
- Deep gouges in walls exposing the dry-wall under the paint were observed in a washroom and a bedroom. It was reported the damage was due to equipment hitting the walls.
- A bedroom fire-rated door was missing the doorknob and had a section cut out of it preventing it from being able to be securely closed or locked and did not ensure the privacy of the PIC.
It was confirmed that a repair plan had been developed and supplies ordered to complete the required repairs.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: October 20, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: Persons in care are permitted into the laundry room to participate as able, however the floor does not have a slip resistant surface as required.
Corrective Action(s): Please ensure a slip resistant floor surface is in place.
Date to be Corrected:
POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: A policy used to guide staff in the administration of medication was reviewed and it was determined it did not comply with the Pharmacy Operations and Drug Scheduling Act when it provided information to staff on PRN over-the-counter medications that could be administered without a physicians order (prescription). The Health Professions Act Bylaws, Schedule F, Part 3 6.(1) Prescription Authorizations requires an prescription to be received prior to dispensing a medication.
It was confirmed however the practice of medication administration is in compliance and the policy requires review .
Corrective Action(s): Please ensure the policies established and reviewed by the MSAC comply with the required Acts.
Date to be Corrected: October 20 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: Policy requires staff on each shift to complete and document a balance check of the financial records for persons in care (PIC). The records of one PIC were reviewed and on 19 occasions over 25 days, staff did not document that the checked occurred as required.
Corrective Action(s): Please ensure staff implement the policies as required.
Date to be Corrected:
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: The care plan for one person in care (PIC) was reviewed and it was confirmed a change in the PICs safety equipment had occurred and the care plan not updated.
Corrective Action(s): Please ensure that care plans are modified when a substantial change occurs.
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: Records for one person in care were reviewed and two of the eight months reviewed had no weights recorded.
Corrective Action(s): Please ensure persons in care are weighed at least once each month.
Date to be Corrected:
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