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: Inspection of the physical facility found that an electric baseboard heater in the family room was missing its front cover. Additionally, in one PIC's room, there was a blind on a French door that had a broken valence that requires repair, replacement or removal.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: March 17, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Above a PIC's bed, there were multiple pictures framed in glass which is a safety concern if they were to fall on the PIC while in bed.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe condition.
Date to be Corrected: As soon as possible
POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: A review of the facility's Medication Safety and Advisory Committee (MSAC) meeting minutes showed that the last recorded MSAC meeting occurred on March 7, 2019.
Corrective Action(s): Ensure that the MSAC meets at least one per year so that the pharmacist can visit and audit the medication room in order to ensure that medications are safely and effectively stored, medication policy and procedures are reviewed, and so that any medication errors can reviewed by the supervising pharmacist.
Date to be Corrected: March 31, 2021
POLICIES AND PROCEDURES: 33220 - RCR s.85(1)(a) - A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Observation: It was observed that electronic surveillance is being used to monitor a PIC when in bed. When asked if there was a policy in place to guide staff around how and when to use this equipment, facility management relayed that there is no written policy in place.
Corrective Action(s): Ensure that there is a written policy in place to guide staff regarding the use of electronic surveillance relating to the care and supervision of persons in care. The licensee must ensure that this policy complies with RCR 19 (3) which states that "the licensee must display in a prominent place notice that electronic surveillance is being used."
Date to be Corrected: March 3, 2021
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: A review of the facility's policies and procedures found that there was no record of policies being reviewed since 2017. It was observed that the facility's smoking policy did not include information addressing the use of marijuana or vapor products.
Corrective Action(s): Ensure that facility policies and procedures are reviewed and, if necessary revised, at least once each year.
Date to be Corrected: March 17, 2021
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