PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: The water temperature in 3 bathroom sinks used by persons in care ranges from 52-55 degrees Celsius.
Corrective Action(s): Please ensure that the water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Date to be Corrected: May 13, 2024
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: PRN medication effectiveness were not recorded to 6 persons in care.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: May 13, 2024
CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: Two of 4 persons in care has no recreation and leisure plan. In discussion with the staff, persons in care (PICs) are participating in the activities, however the activities were not included in the PIC's care plans. The facility has no recreation manager since August 2023.
Corrective Action(s): Please ensure that care plans include a recreation and leisure plan for all persons in care.
Date to be Corrected: May 13, 2024
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: Two of 4 persons care's care plan does not have the updated nutrition care plan. The facility has no Dietitian since August 2023.
Corrective Action(s): Please ensure that each care is reviewed and, if necessary, modified at least once each year.
Date to be Corrected: May 13, 2024
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Five unlabelled food in a container were stored in the dining room refrigerator.
Corrective Action(s): Please ensure that all food is safely stored.
Date to be Corrected: May 13, 2024
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: No weight was taken for all persons in care for the months of August, September, October, November and December 2023
Corrective Action(s): Please ensure that the each person in care is weighed at least once each month.
Date to be Corrected: May 13, 2024
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