LICENSING: 30020 - RCR s.8(2)(a)(i) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (i) plans for the change.
Observation: It was observed that the hairdressing area, shower room, and a recreation office area and outside roof, were all in the process of being renovated. The licensee did not submit the required plans for the change or a plan to address the health and safety of persons in care during the renovations or receive written approval from the medical health officer prior to the work starting. This contravention includes RCR s. 8(2)(a)(ii)(b).
Corrective Action(s): Ensure structural changes are not made without first submitting plans to the medical health officer with a plan for the health and safety of the persons in care during the changes. This includes first getting approval before the structural change occurs.
Date to be Corrected: November 9, 2016
LICENSING: 30030 - RCR s.8(2)(a)(ii) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (ii) a description of how the licensee intends to ensure the health and safety of persons in care while the change is being made.
Observation: Please refer to code 30 020 RCR s. 8(2)(a)(i)
Corrective Action(s):
Date to be Corrected:
LICENSING: 30040 - RCR s.8(2)(b) - A licensee must not make any structural change to a community care facility unless the licensee (b) receives written approval from the medical health officer.
Observation: Please refer to code 30 020 RCR s. 8(2)(a)(i)
Corrective Action(s):
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Upon an audit of 5 resident areas, the water temperatures in 3 out of 5 bedrooms exceeded 49 degrees Celsius.
Corrective Action(s): Ensure water accessible to persons in care does not exceed 49 degrees celsius.
Date to be Corrected: December 15, 2016
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: 3 out of 5 bedrooms were observed to have damage to walls in the bedrooms and bathrooms, with 1 bedroom especially damaged with more than 2 holes through the jiprock in the walls exceeding atleast 3 square inches.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: December 15, 2016
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: The following was observed:
- In 3 of 4 Records of Care, for the months of October and November 2016, documentation has not been consistently completed in more than 10 boxes for each record.
- in 2 of 4 care records – Pre-move in form missed signatures and dates for completion for atleast 2 items on each form.
- in1 record of 4 – admission checklist was not completed.
Corrective Action(s): Ensure staff are implementing policies and procedures.
Date to be Corrected: December 15, 2016
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