STAFFING: 32250 - RCR s.44(1)(a) - A licensee must ensure that employees responsible for the preparation and delivery of food (a) have the experience, competence and training necessary to ensure that food is safely prepared and handled and meets the nutrition needs of the persons in care.
Observation: Discussion with food service staff determined that one staff's food safe had expired in May 2019.
Corrective Action(s): Ensure that all employees records are current and complete.
Date to be Corrected: January 13, 2020
POLICIES AND PROCEDURES: 33220 - RCR s.85(1)(a) - A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Observation: Discussion with staff determined that some PIC's will not take their morning medications either because of refusal or preference. Staff will try to administer at a later time depending on the medications and this is a confirmed regular practice. Review of the policies and procedures could not find the medication administration policy to outline this procedure or confirm that staff are following the facility's policy for medication administration and/or refusal.
Corrective Action(s): Ensure that all policies and procedures are complete.
Date to be Corrected: January 13, 2020.
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: The policies and procedures were last reviewed on November 2018.
Corrective Action(s): Ensure that the policies and procedures are reviewed at least once each year.
Date to be Corrected: January 13, 2020
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: Review of the daily care plan documentation found that there was missing initials and blank boxes. It appears that care is being provided but staff are not documentating the care in the daily care plan.
Corrective Action(s): 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.
Date to be Corrected: January 13, 2010
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: Review of the medication storage area found 5 expired medications.
Corrective Action(s): Ensure that a person in care's medication is returned to the dispensing pharmacy if they expiry date on the medication has passed.
Date to be Corrected: January 13, 2020
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (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: A review of the weights for persons in care (PIC) found that 3 weights were missing for November 2019. Discussion with staff determined that PIC's refuse to be weighed.
Corrective Action(s): Ensure that each person in care is weighed at least once each month or the reason why the person in care could not be weighed is recorded.
Date to be Corrected: January 13, 2020
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