PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation:
PIONEER
3 office type chairs at the card table are worn and torn in spots and 1 has the arm rest taped together with black duct tape
The fridge in the PIC’s snack kitchen has a broken plastic vegetable drawer that has sharp edges
Broken wall mirror in the gym with duct tape on it
Railing going to the downstairs level is missing paint in some areas and is chipping in other areas
The metal part of the toilet paper holders are rusty and corroded in 3 of the bathrooms
CRESST
General wear and tear of bathtubs and showers – caulking coming off and staining of bottom of the showers and tubs
Corrective Action(s): Ensure all furniture and equipment used by persons in care is maintained in a good state of repair
Date to be Corrected: November 9, 2018
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:
PIONEER
Several spots in the bedrooms where paint was chipping or patches of damage were noted due to rubbing of headboards or chair backs
Light cover in the janitor room was broken
Cords for gaming machines on the floor in the Game room unorganized an posed a possible tripping hazard (CORRECTED DURING INSPECTION)
CRESST
Missing light cover in one bathroom (CORRECTED DURING INSPECTION)
Smoking area metal walls are dirty and stained
Corrective Action(s): Ensure all rooms and common areas are maintained in a state of good repair
Date to be Corrected: November 9, 2018
STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: It was observed that out of 5 staff files reviewed 1 file was missing the criminal record check. Through conversation it was noted that the staff had requested a CRC at another agency and would share it with Pioneer house once received
Corrective Action(s): Ensure all employees have a valid criminal record check
Date to be Corrected: October 19,2018
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: CRESST- It was noted during review of 3 MAR sheets that the response section of the nurses notes were not completed on all 3 MAR's
Corrective Action(s): Ensure that employees are implementing the policies and procedures related to medication documentation
Date to be Corrected: October 19,2018
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: CRESST- review of 2 PIC's binders found that 2/2 did not have any information related to TB screening. 1/2 binders reviewed had an Immunization form but it was not completed.
Corrective Action(s): Ensure that all PIC's have evidence in their records of compliance to the provinces TB immunization programs
Date to be Corrected: November 2, 2018
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: In one fridge used by PIC's it was noted that there was unlabeled food items stored in the fridge (CORRECTED DURING INSPECTION)
Bread stored in the freezer was not organized to ensure proper rotation of new and old items
Corrective Action(s): Ensure all food is safely prepared, stored, served and handled
Date to be Corrected: October 19, 2018
MEDICATION: 36080 - RCR s.69(1)(b) - A licensee must ensure that a pharmacist (b) records all medications on the person in care's medication administration record.
Observation: CRESST- it was noted during review of 3 MAR's the MAR's had handwritten directions completed by staff. This is a repeat contravention from the previous inspection. This staff practice is done because there are a number of frequent changes done to medications and pharmacy does not provide MARS. Through discussion the manager will contact the pharmacy to request extra labels to put on the MAR when they get new medications delivered
Corrective Action(s): Ensure that the pharmacist records all medications on the PIC's MAR
Date to be Corrected: October 19,2018
MEDICATION: 36160 - RCR s.72(a) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (a) the person in care is no longer taking the medication.
Observation: CRESST- One medication vile brought in by the PIC was stored in the bin used for medication storage of the PIC's daily medications.
Corrective Action(s): Ensure medications not labeled by the pharmacy and not being used by the PIC are returned to the pharmacy
Date to be Corrected: October 12,2018
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