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- General RequirementsPrograms & adminOrder
Inspectors found that the home did not complete written evaluations for its Skin and Wound, Falls, and Pain Programs for 2025, and the 2024 evaluations were missing required documentation such as the date each evaluation was completed and the names of staff who participated. The home has been ordered to complete the 2025 evaluations and ensure all future program evaluation records include these required details.
- Skin And Wound CareSkin & woundOrder
Inspectors found that the home did not consistently assess and reassess residents with skin wounds or injuries. Specifically, some residents did not receive weekly reassessments by a nurse, and assessments that were done did not always use proper wound assessment tools or include pain evaluation, which meant the extent of wound problems and resident pain went unrecognized.
- Pain ManagementPainOrder
Inspectors found that the home did not assess three residents using appropriate pain assessment tools when their pain was not relieved by initial treatment. The home has been ordered to revise its pain management policy, train nursing staff on the revised policy, and ensure staff respond to pain alerts generated by the home's electronic system.
- Responsive BehavioursResponsive behavioursOrder
The home did not have adequate systems in place to monitor, assess, and respond consistently to residents with responsive behaviours. Inspectors found that for ten residents identified as having significant behavioural support needs, the home lacked clear protocols for tracking behaviour, referring residents to specialized support services, coordinating care across staff and specialists, documenting triggers and intervention responses, and evaluating the effectiveness of its responsive behaviour program. Staff were unclear about roles and responsibilities, and care was not consistently delivered based on each resident's assessed needs or in a coordinated, team-based approach.