LICENSING: 30020 - RCR s.8(2)(a)(i) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (i) plans for the change.
Observation: Licensing was not informed of the following renovations:
- full renovation to PIC bathroom
- flooring in PIC bedrooms and to greater than half of the indoor common space
PIC's had limited access to areas within the home during the three-week renovation.
Corrective Action(s): Ensure a plan is submitted to licensing prior to structural changes. Please also ensure a description of how safety will be ensured during the changes as per RCR s. 8(2)(a)(ii).
Date to be Corrected: July 29, 2022
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Monthly fire drills were held twice in the past year.
Corrective Action(s): Ensure policies are implemented by employees.
Date to be Corrected: August 12, 2022
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: In the past year, health professionals directed changes to a care procedure of one PIC. The plan of care was not updated to guide staff in implementing the changes.
Corrective Action(s): Ensure care plans are reviewed and updated.
Date to be Corrected: July 29, 2022
NUTRITION AND FOOD SERVICES: 37050 - RCR s.62(2)(c)(i) - A licensee must ensure that each menu provides (c) a variety of foods, taking into consideration (i) the nutrition plan of each person in care and the nutrition needs, age, gender and level of activity of the persons in care.
Observation: The nutritional value of the menu could not be determined due to unspecified number of servings from each food group. Items were selected from a list for lunches and snacks but there was not a system in place to guide the number and variety of food groups to be included in these meals.
Corrective Action(s): Ensure menus consider nutritional needs.
Date to be Corrected: August 12, 2022
RECORDS AND REPORTING: 39230 - RCR s.79(1)(a) - A licensee must keep a record in respect of each person in care showing the following information: (a) all money, valuables and other things held by the licensee in trust or safekeeping for persons in care.
Observation: Eleven gift cards belonging to persons in care were held in trust without record.
Corrective Action(s): Ensure records of all money and values is kept.
Date to be Corrected: August 5, 2022
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