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: Temperature of water in one unit was 52.6 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: July 10, 2020
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: Door for bedside table for a person in care was broken. Two gates in one kitchenette are in need of repair in order to close properly.
Corrective Action(s): Please ensure that all furniture and equipment for use by person in care is maintained in a good state of repair.
Date to be Corrected: July 10, 2020
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: Two walls in one tub room had holes extending through the drywall and exposing the inside of the wall. Peeling wallpaper note in one kitchenette.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: July 10, 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 unlocked or propped open. These contained items that could be hazardous to persons in care: Two dirty utility rooms, elevator maintenance room, and a medical room that provides access to storage room. The keys to the locked tub rooms hand beside the doors leaving them unsecured.
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: July 10, 2020
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: One person in care had two medications stored in their bedside table.
Corrective Action(s): Please ensure that all medications are safely and securely stored.
Date to be Corrected: July 10, 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: July 10, 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: A review of policies that were available to staff were insufficient to guide staff in matters relating to care and supervision for the persons in care at the facility.
Corrective Action(s): Please ensure that the facility has written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Date to be Corrected: July 10, 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: July 10, 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: July 10, 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: One person in care is at risk for falls and does 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: July 10, 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 (PIC) has become visually impaired, now requires wound care, now has specific instructions related to positioning and mobility from a professional consult, and now utilizes specialty equipment.
A second PIC experienced a fractured hip and now requires fall prevention measures such as a fall mat, bed alarm and bed inlowest position.
For both PIC these changes occurred after admission and information was not updated on either PICs 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 int he circumstances of the person in care.
Date to be Corrected: July 10, 2020
CARE AND/OR SUPERVISION: 34830 - RCR s.83(2) - A licensee of a community care facility with more than 24 persons in care must develop, with the assistance of a dietitian, a nutrition plan for each person in care.
Observation: One person in care did not have evidence of a nutrition plan.
Corrective Action(s): Please ensure that each person in care has a nutrition plan developed with the assistance of a dietitian.
Date to be Corrected: July 10, 2020
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Over a 4 month period of time, a person in care went 3 weeks between baths on 3 separate occasions without alternative care provided or documented.
Corrective Action(s): Please ensure an established program to instruct, if necessary, and assist person in care in maintaining health and hygiene.
Date to be Corrected: July 10, 2020
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Menu did not contain documented evidence of two food groups presents in each of the two snacks offered.
Corrective Action(s): Please ensure that each menu provides for each day, at least two nutritious snacks, with each snack containing at least 2 food groups.
Date to be Corrected: July 10, 2020
PROGRAM: 38010 - RCR s.55(1)(a)(i) - A licensee, other than a licensee who provides a type of care described as Hospice, must (a) provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities (i) suitable to the needs of the persons in care.
Observation: One person in care did not have evidence of a planned program of activities.
Corrective Action(s): Please ensure that each person in care has a planned program of physical, social and recreational activities suitable to their needs.
Date to be Corrected: July 10, 2020
RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: One person was admitted into care without documenting admission weight and height
Corrective Action(s): Please ensure that the height and weight of each person in care is recorded upon admission.
Date to be Corrected: July 10, 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 administration 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: July 10, 2020
RECORDS AND REPORTING: 39310 - RCR s.81(1) - If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: One person who has been in care for more than 30 days does not have a comprehensive care plan.
Corrective Action(s): Please ensure that if a person in care has been admitted for a period of more than 30 days, that a comprehensive care plan is developed.
Date to be Corrected: July 10, 2020
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