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: A commode located in a person’s room (bathroom) was partly full at 9:30am on day 1 of this inspection. This commode was partly full at 2:45pm on day 3 of this inspection. Information provided was that this commode was emptied and disinfected at the beginning of each shift and, more often than not, a second time at the end of each shift.
Corrective Action(s): It is a requirement that staff maintain equipment used by persons in care (PIC) in a clean condition. Not emptying and disinfecting a partly full commode for extended periods does not meet this requirement.
Date to be Corrected:
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: Water was observed on a small hallway located on the 6th floor. This hallway was located almost directly across from the nurse’s station and it led to a couple of non-resident rooms. According to the information provided during this inspection, this occurred intermittently due to condensation forming on piping and dripping onto this floor. This area was accessible to persons in care and water on the floor presented a potential risk for falls.
Corrective Action(s): Please address this maintenance need.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: An annual inspection of fire equipment (such as fire extinguishers) was 3 weeks overdue at the time of this inspection.
Corrective Action(s): Please ensure that, as soon as reasonably possible, that these fire systems are inspected.
Date to be Corrected:
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: Denture toothbrushes were observed in 2 person in care's bathrooms lying with bristles down on a counter top alongside a sink.
A paper towel dispenser was empty in a person in care's bathroom. It was evident that this bathroom's toilet had recently been used (toilet had not been flushed) and there was no other means immediately avaialble for a person to wipe their hands. (Paper towels were observed in all other rooms inspected.)
Corrective Action(s): Please ensure that needed supplies (such as paper towels) are available and equipment used for dental care is stored in a manner to promote health and hygiene.
Date to be Corrected:
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: The following was determined after a random review of person in care's records:
Six persons did not have their weight recorded for 1 or more months between September 1, 2019 and April 30, 2020.
- Three of 6 did not have their weights recorded on 1 or months between September 1, 2019 and December 31, 2019.
- Three of 6 were identified as being at high risk due to low body weight.
- One of the 3 high risk person’s weight had been documented 2x between from September 1, 2019 and April 30, 2020 and their weight for May 2020 had not been recorded at the time this inspection (May 27, 2020).
A reason why these persons were not weighed was not documented.
A 7th person’s weight was recorded on April 2, 2020 and then again on May 24, 2020. This person was identified as being at high risk due to low body weight.
There was inconsistent follow-up to a dietitian requests for persons at high risk to be weighed as soon as possible.
Corrective Action(s): Please ensure that persons in care are weighed monthly, or more frequently where ordered.
Not regularly monitoring the weight of persons in care at high risk due to low body weight is potentially considered a high risk contravention to legal requirements.
Date to be Corrected:
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