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- Food ProductionNutrition & diningOrder
Inspectors found that during a meal service, a resident discovered a hard clear plastic piece in their food, but staff did not remove the contaminated food from residents on that specialized diet. The home's management acknowledged that staff should have immediately stopped serving and removed the food. The home was ordered to develop and implement written procedures for all staff involved in meal service on how to respond to suspected or actual food contamination, and to keep records of when these procedures were shared with staff.
- Residents’ Bill Of RightsResidents' rights
Inspectors found that the home did not ensure a resident's privacy during personal care on three separate occasions. Video footage showed the resident's bedroom door was left open while staff provided care when the resident was unclothed, and on one occasion staff removed the resident's blanket and left it out of reach while the door remained open.
- Residents’ Bill Of RightsResidents' rights
Inspectors found that staff administered a medication to a resident without obtaining required consent from the resident's substitute decision maker beforehand, contrary to the home's own medication record directions.
- Plan Of CareCare planning
Inspectors found that staff did not consistently collaborate on assessing residents when changes in their condition were observed. In one case, a change was noted but no further assessments were documented until two days later. In another case, staff observed a change but did not assess the resident during subsequent shifts, and a referral to a doctor was not followed up promptly. A complaint was also received about a treatment protocol being started without proper collaboration among staff in assessing the resident's condition.