PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: The night tables that were missing locks during the previous inspection were still missing their locks during this inspection. Management confirms that this repair is on the facility's to do list.
Corrective Action(s): Ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair.
Date to be Corrected: November 26, 2021
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: The painting of doors throughout the facility has not yet been completed. Facility management confirms that the required painting is a work in progress. In order to prevent paint from being removed from doors going forward, management relayed that plastic sleeves will be installed on the doors so that signs will no longer need to be taped directly on doors.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: November 29, 2021
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: Required employee performance reviews are not yet completed. Management reports that they are in the process of completing these reviews.
Corrective Action(s): Ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that employees demonstrate the competence required for the duties to which they are assigned.
Date to be Corrected: November 29, 2021
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: A review of the facility's emergency supplies found that there is still insufficient food and water to sustain all persons in care and staff for three days in the event of an emergency.
Corrective Action(s): Ensure that an emergency plan sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Date to be Corrected: November 29, 2021
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: A review of care plans for persons in care found that one care plan called for a person in care (PIC) to wear hip protectors and required the PIC's bed to be in the lowest position; however, it was observed that the PIC was not wearing hip protectors and that the PIC's bed was not in the lowest position contrary to the PIC's care plan. Additionally, the same PIC's room had a fall mat in place which was not noted in the PIC's care plan.
Corrective Action(s): Ensure that the care and supervision of persons in care is consistent with the terms and conditions of the care plans of the persons in care.
Date to be Corrected: November 2, 2021
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