PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31050 - RCR s.15(1) - A licensee must ensure that, if necessary for the health and safety of a person in care, windows are secured in a manner that prevents a person in care from falling from, or exiting through, the window.
Observation: During inspection of the physical facility, windows were noted to not be secured in a manner that would prevent a person in care from falling from or exiting through. It appeared that some windows had mechanical locks in place, however these locks were no longer in working condition.
Corrective Action(s): Please ensure that windows are secured in a manner that prevents a person in care from falling from or exiting through the window.
Date to be Corrected: April 14, 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: In discussion with staff regarding employee performance reviews, it appears several staff have not had an employee evaluation for several years. At the time of inspection, it was not clear how often employee evaluations take place.
Corrective Action(s): Please ensure that the performance of each employee is reviewed both regularly and as directed by facility policy.
Date to be Corrected: Please provide a response by April 19, 2022 as to how employee evaluations will be completed regularly and as directed by facility policy.
CARE AND/OR SUPERVISION: 34600 - RCR s.81(3)(a)(i) - A care plan must include all of the following: (a) a plan to address (i) medication, including self-administered medication if approved under section 70 (4) [administration of medication].
Observation: In review of the care plans for 8 persons in care, it was noted that medications are not captured as a care plan component/focus area.
Corrective Action(s): Please ensure that all persons in care have a care plan that includes 'a plan to address medications.'
Date to be Corrected: April 18, 2022
CARE AND/OR SUPERVISION: 34680 - RCR s.81(3)(e)(ii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (ii) a plan for preventing the person in care from falling.
Observation: In review of a person in care's care plan, it was noted that a 'falls' care plan was not in place. The person in care had been admitted to the facility for more than 30 days.
Corrective Action(s): Please ensure that all persons in care have a fall prevention plan in place.
Date to be Corrected: April 4, 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: During inspection of spa rooms and person in care bathrooms, the following was observed:
- numerous nail cutters were found without any resident identifiers in drawers and on counter tops,
- in some rooms personal items such as toothbrushes and coombs were left in unlabelled containers and on counter tops.
Corrective Action(s): Please ensure a program is in place to assist persons in care in maintaining health and hygiene.
Date to be Corrected: April 14, 2022
RECORDS AND REPORTING: 39300 - RCR s.80(2) - Anything that must be recorded in a care plan under this regulation must be recorded in the short term care plan until a care plan is developed.
Observation: In review of 8 persons in care 'care plans', it was noted that the 'short term care plans' are not addressing several required care components/focus areas. For instance, all 8 short term care plans did not provide any directions regarding medications. As well, 4 short term care plans did not address oral care, and 2 did not address fall prevention.
Corrective Action(s): Please ensure that required care plan components under this regulation are recorded in the short term care plan until a comprehensive care plan is developed.
Date to be Corrected: April 4, 2022
RECORDS AND REPORTING: 39310 - RCR s.81(1) - If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: In review of a person in care's health care records, it was noted that a comprehensive care plan had not been developed. The person in care had been admitted to the facility for more than 30 days.
Corrective Action(s): Please ensure that a comprehensive care plan is in place for persons in care who have been admitted to the facility for more than 30 days.
Date to be Corrected: April 4, 2022
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: In review of the weight records for persons in care, it was noted that monthly weights are not being recorded for all persons in care. For 1 person in care, monthly weights were missing for December 2021, January 2022, and February 2022.
Corrective Action(s): Please ensure that each person in care is weighed at least once each month. If a person in care is unable to be weighed, please ensure that the reason is documented.
Date to be Corrected: April 4, 2022
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