PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Of eight temperatures tested throughout the facility, six were above 49 degrees Celsius.
Corrective Action(s): Please ensure that water accessible to persons in care is not more than 49 degrees Celsius.
Date to be Corrected: November 13, 2020
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Multiple areas left accessible by either doors being left unlocked, propped open, keys in locks or keys hanging beside door. These areas contained items that could be hazardous to persons in care. Areas observed and found unsecured were dirty utility rooms and tub rooms.
Corrective Action(s): Please ensure that areas that contain cleaning agents, chemical products and other hazardous materials are safe and secure for persons in care.
Date to be Corrected: November 13, 2020
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: Two persons in care use a lap belt to restrict their movements while in their wheelchair. There is no evidence of agreements in place.
Corrective Action(s): Please ensure there is an agreement to the use of a restraint given in writing by both the person in care, the parent or representative of the person in care of the relative who is closest to and actively involved in the life of the person in care.
Date to be Corrected: November 13, 2020
CARE AND/OR SUPERVISION: 34350 - RCR s.63(3)(c)(ii) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (ii) indicated in the care plan of a person in care.
Observation: One person in care who receives on-going tray service does not have it documented in their care plan.
Corrective Action(s): Please ensure that on-going tray service is indicated in the care plan.
Date to be Corrected: November 13, 2020
CARE AND/OR SUPERVISION: 34650 - RCR s.81(3)(c)(ii) - A care plan must include all of the following: (c) a nutrition plan that (ii) specifies the nutrition to be provided to the person in care, including the requirements of any therapeutic diets.
Observation: One person in care receives a therapeutic diet that is not documented on the care plan.
Corrective Action(s): Please ensure that if a person in care receives a therapeutic diet, that it is included in the care plan.
Date to be Corrected: November 13, 2020
CARE AND/OR SUPERVISION: 34670 - RCR s.81(3)(e)(i) - 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 (i) an assessment of the nature of the risk of falling presented by the person in care.
Observation: Two persons in care who are at risk for falls did not have evidence of a fall prevention care plan.
Corrective Action(s): Please ensure that persons in care have a fall prevention plan included in their care plan as applicable.
Date to be Corrected: November 13, 2020
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: A person in care has become visually impaired, and has specific instructions related to positioning and mobility from a professional consult, and now utilizes specialty equipment. These changes occurred after admission and information has not been updated on the care plan as required.
Corrective Action(s): Please 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: November 13, 2020
RECORDS AND REPORTING: 39200 - RCR s.78(2)(b) - A licensee must keep, for each person in care, a medication administration record showing (b) the date, amount and time at which the medication was administered.
Observation: Medication records were reviewed and was noted that not all medications were signed as being administered as ordered.
Corrective Action(s): Please ensure that medication administration records indicate the date, amount and time at which the medication was administered.
Date to be Corrected: November 13, 2020
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