Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
21-Mar-2024
Subject
["Policies (Includes issues such as not following, insufficient information or policy missing)","Nutrition and Food Service (Includes issues such as consistency, quantity, quality, feeding assistance, timing, etc.)","Medication (Includes issues such as missing, inappropriate use/overuse of medications, errors, etc.)","Health and Safety","Neglect","Recordkeeping (Includes issues such as not keeping records, insufficient records, care planning issues, health care consent, admission records.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must 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
Observation: Through the investigation process, Licensing determined that care plans for persons in care had not been updated when there was a substantial change to circumstances.
Corrective action: Ensure the each care plan is reviewed, and if necessary, modified is there is a substantial change in the circumstances of the person in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On June 27 and August 1, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included a care conference was held and a person in care's care plan was updated to address the new health and safety concerns and a person in care no longer resided at the facility. The corrective action plan was reviewed and accepted by Licensing. On July 8, 2024, Licensing received a copy of the updated care plan.
A licensee must ensure that no one other than a person in care engages in a restricted activity while on the premises of the community care facility
Observation: Through the investigation process, Licensing determined that employees had engaged in restricted activities while on the premise of the community care facility.
Corrective action: Ensure that no one other than a person in care engages in a restricted activity on the premise of a community care facility. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On June 27, and August 1, 2024 Licensee submitted a corrective action plan to Licensing. The corrective action plan inlcuded a new policy that was developed prohibiting employees from smoking on the premise and all employees would sign the policy by July 5, 2024. The corrective action plan was reviewed and accepted by Licensing. On July 9, 2024, Licensing received a copy of the signed policy.
A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Observation: Through the investigation process, Licensing determined that the licensee had not operated the community care facility in a manner which promoted the health, safety, and dignity of persons in care. Specifically, discarded cigarettes had not been disposed of in a proper receptacle.
Corrective action: Ensure to operate the community care facility in a manner which promotes the health, safety and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On June 27 and August 1, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that a new policy was created to ensure discarded cigarettes were cleaned up, all persons in care would be responsible for cleaning up cigarettes daily and, If needed, Saturday would be a designated day for all to participate in the clean up, the policy was presented at the Resident Council Meeting on June 26, 2024 and all staff would sign the new policy by July 5, 2024. The corrective action plan was reviewed and accepted by Licensing. On July 9, 2024 Licensing received a copy of the signed policy.
Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer
Observation: Through the investigation process, Licensing determined that a person in care was involved in a reportable incident and the medical health officer was not informed immediately.
Corrective action: Ensure that if a person in care is involved in a reportable incident, the licensee must immediately notify the medical health officer, in the form and in the manner required by the medical health officer. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On June 27 and August 1, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that the incident reporting policy was updated to ensure that staff reported incidents when the Manager was not on site. The corrective action plan was reviewed and accepted by Licensing. On August 8, 2024, Licensing received a copy of the amended policy.
A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Through the investigation process, Licensing determined that food had not been safely, prepared, stored, served and handled.
Corrective action: Ensure that food has been safely prepared, stored, served and handled. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On June 27 and August 1, 2024 Licensee submitted a corrective action plan to Licensing. The corrective action plan included that all staff were required to review the Food Safety Plan policy and sign it. The corrective action plan was reviewed and accepted by Licensing. On July 9, 2024, Licensing received a copy of the signed policy.