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: A small section of the wall above the fire alarm located on Ruskin Hill was observed with spackle measuring approximately a foot in length by a foot in width which required painting.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: February 3, 2023
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: Inspection of a medication cart on Haney Lane found there to be one insulin syringe whereby there was not a start date and/or use-by date. Of concern is there was not a date to guide staff as to when the syringe should be discarded as they are to be opened and in use within a certain time frame.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: February 3, 2023
CARE AND/OR SUPERVISION: 34570 - RCR s.75(3)(b) - If a restraint is used under section 74(1)(b) and the use of the restraint continues either continuously or intermittently for more than 24 hours, a licensee must (b) as part of the reassessment, consult, to the extent reasonably practical, with the persons who agreed to the use of the restraint.
Observation: A PIC was observed with a lap buddy restraint. Review of the PIC's care plan indicated use of this restraint however, the restraint agreement form found in the care plan was not reassessed since April 2021.
Corrective Action(s): A licensee must ensure reassessment includes consultation with the persons who agreed to use the restraint.
Date to be Corrected: February 3, 2023
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: Discussion with leadership confirmed a PIC required ongoing tray service. However, there was no documentation found in the PIC's care plan indicating the PIC was receiving ongoing tray service.
Corrective Action(s): Ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care.
Date to be Corrected: February 3, 2023
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Review of 2 of 12 admission records found no evidence of tuberculosis screening and review of 6 of 12 admission records found incomplete records of immunization for persons in care.
Corrective Action(s): A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: February 3, 2023
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 of the tub room located on the second floor found four nail clippers without any labels or identifiers.
Corrective Action(s): Ensure items are labelled or placed in individual containers for PIC.
Date to be Corrected: February 3, 2023
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: Review of 5 PIC's weight charts determined that a weight was not captured for the month of October 2022 and there was no documentation provided to explain why the weight was missing.
Corrective Action(s): Ensure that each person in care is weighed at least once a month or provide a reason as to why the weight could not be obtained.
Date to be Corrected: February 3, 2023
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