PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: It was observed in 1 person in care's room a bookshelf that was provided by family had not been secured to the wall.
Corrective Action(s): Please ensure that any furniture that is provided by family and could pose a safety risk is secured appropriately.
Date to be Corrected: March 5, 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 a walk through of the physical facility, it was noted in several areas that the wooden hand railing was scratched and dented. In one section, the hand railing had worn down and a small area of wood was missing. The concern is that these damaged railing surfaces would not be able to be cleaned and santized appropriately. In one of the sitting rooms, a face plate was missing with what appeared to be exposed telephone wires.
Corrective Action(s): Please ensure that all common areas are maintained in a good state of repair.
Date to be Corrected: March 19, 2021
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 (CORRECTED DURING INSPECTION): It was noted that a door to the room titled 'Laundry' was left open and accessible to persons in care. Cleaning agents were observed being stored in this room on the floor. It was discussed with the DOC that this room is usually kept locked.
Corrective Action(s): Please ensure that cleaning agents or chemicals are stored in a secure storage area that is not accessible to persons in care.
Date to be Corrected: Corrected at the time of inspection.
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: In discussion with facility staff regarding the employee evaluations, it was confirmed that performance reviews have not been completed for year 2020. It was confirmed that the facility's policy requires annual performance reviews for all staff.
Corrective Action(s): Please ensure that regular performance reviews are completed for all staff as directed by facility policy.
Date to be Corrected: May 19, 2021
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: In review of the Policy and Procedure Manual, several policies were noted to have been reviewed and/or revised in September 2019. The Fall Prevention Policy was last reviewed on 2019-09-26.
Corrective Action(s): Please ensure that policies and procedures are reviewed at least once each year.
Date to be Corrected: May 19, 2021
CARE AND/OR SUPERVISION: 34680 - RCR s.81(3)(e)(ii) - 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 (ii) a plan for preventing the person in care from falling.
Observation: In review of the care plans for persons in care, it was noted for 1 person in care that a falls care plan was not in place.
Corrective Action(s): Please ensure that persons in care have a falls prevention plan to address risk of falls.
Date to be Corrected: March 5, 2021
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: In review of weight records for persons in care, it was noted that a person in care's weight was missing for January 2021 and December 2020.
Corrective Action(s): Please ensure that each person in care is weighed at least once each month, and if weights are not able to be obtained, that the reason why is documented in the records.
Date to be Corrected: March 5, 2021
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