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- Plan Of CareCare planning
Inspectors found that the home's plan of care for a resident did not provide clear directions to staff about when to give the resident's medication. The medication order specified that the medication should not be given with food, but the home had scheduled the medication to be given at the same time as a meal, creating confusion for staff about how to safely administer it.
- Nutritional Care And Hydration ProgramsNutrition & dining
Inspectors found that the home did not have a system to routinely monitor and evaluate food and fluid intake for residents at nutritional risk. For one resident reviewed over two weeks, there were nine days with less than 1000mL of fluid intake and two days with no recorded food or fluid intake. Staff interviewed indicated that responsibility for reviewing this data was unclear: the dietitian said nurses should review it, nurses said the dietitian should review it, and management stated that food and fluid data entered by personal support workers was not routinely evaluated by anyone.
- Administration Of DrugsMedication
Inspectors found that staff members administered a resident's medication with meals and snacks on two occasions, contrary to the physician's written directions that the medication should not be given with food.
- Resident RecordsPrograms & admin
Inspectors found that the home did not keep a resident's records up to date. Food and fluid intake that inspectors observed the resident consuming was not recorded in the home's tracking system, and an admission weight recorded in the resident's file was not actually measured by staff on the date documented but was instead copied from the resident's paperwork without being verified.