LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: In review of the care planning system it was noted for a person in care that their fall risk assessment is in-place, however there is no date documented. On November 3, 2021, the Manager responded that the Team Leads for each care floor have communicated the expectations to the care staff.
Admission documents were not fully completed such as Identification of Decision Maker and the Licensing Officer was made aware these should be completed within 1 week of admission.
Corrective Action(s): Please ensure the care and services provided by the community care facility is regularly monitored to ensure that the requirements of the Community Care & Assisted Living Act and Residential Care Regulation are being met.
Date to be Corrected: October 29, 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: During the physical plant inspection of the building, the following were noted, for example:
- Hand rails with painted coming off in various locations.
- Elevator door and person in care bedroom door trims with scuff marks/paint coming off.
- On the first floor outside a staff's office on the left side the bottom rail that is installed throughout the facilty the "end" cap is not in-place.
- The kitchen servery counter tops noted to being showing wear and tear.
- One of the two elevators (for example the elevator nearest each care unit entrance) with one piece of the floor that has come off near the front of the elevator.
In discussion with the Manager, the Manager also completed with other staff a walkthrough of the building and noted:
- That the elevator door trims/person in care door trims including wall hand rails the paint has come off/there are noted scuff marks.
- Persons in care bedrooms counter tops with the laminate is starting to come off.
- Hallways with holes in various locations at the base of the wall where the baseboard meets the wall and this needs to be caulked.
- Kitchen serveries counter tops need to be replaced and that there are cupboards with handles missing.
- 1 tubroom in the corner against the wall has bubbled.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: January 2022.
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: A review of two of the medication rooms indicated that there were a few PRN (as needed) medication entries noted with no result/effect documented.
Corrective Action(s): Please ensure that all staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: November 1, 2021.
CARE AND/OR SUPERVISION: 34220 - RCR s.56(1) - A licensee must ensure that a person in care who leaves a community care facility for a temporary purpose has in his or her possession written documentation indicating the person in care's name, the community care facility's name and emergency contact information.
Observation: In discussion with the Manager and staff member providing persons in care written documentation indicating the person in care's name, the community care facility's name and emergency contact information is not being done on a regular basis.
Corrective Action(s): Please ensure that a person inc are who leaves the community care facility for a temporary purpose has in his or her possession written documentation indicating the person in care's name, the community care facility's name and emergency contact information.
Date to be Corrected: October 29, 2021.
CARE AND/OR SUPERVISION: 34630 - RCR s.81(3)(b) - A care plan must include all of the following: (b) an oral health care plan.
Observation: In review of the care planning system, a person in care did not have a oral care plan in-place.
Corrective Action(s): Please ensure persons in care have a oral health care plan in-place where required.
Date to be Corrected: November 1, 2021.
RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: In review of the care planning system, it was noted for a person in care that their height and weight on admission was not documented.
Corrective Action(s): Please ensure all persons in care have their height and weight documented on admission.
Date to be Corrected: October 29, 2021.
RECORDS AND REPORTING: 39126 - RCR s.77.1(1)(b) - Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: (b) in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable;
Records respecting admission
77.1
(2) Subsection (1) (b) and (c) does not apply to a person in care who is in a program described in section 2 (1) as Child and Youth Residential or is receiving a type of care described in section 2 (2) (d) as Community Living
(4) Subsection (1) (c) applies only in respect of an assessment report provided on or after November 4, 2019
Observation: In review of the care planning system, it was noted that the admission consent for a person in care was not on file.
Corrective Action(s): Please ensure consent for persons in care to be admitted is noted on persons in care records where applicable.
Date to be Corrected: October 29, 2021.
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