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: Testing of 2 water sources showed that both were higher then 49 degrees. one was 52.5 the other was 55
Corrective Action(s): ensure water accessible by persons in care is no higher than 49 degrees
Date to be Corrected: corrected at the time of inspection
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: Review of PIC's equipment noted that the material for the elbow/arm protector is coming off and has been taped on with red electrical tape
Corrective Action(s): Ensure PIC's equipment is maintained in a good state of repair
Date to be Corrected: Dec 6, 2021
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 noted:
Kitchen cupboard doors under the sink have missing laminate which causes sharp edges
Wall damages and baseboard damages through out the home
Corrective Action(s): ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: Dec 6, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: It was noted during inspection that the fire extinguishers through out the house have an expired inspection tag as of November 18, 2021. Maintenance has confirmed that the inspection is to take place on Dec 1, 2021
It was noted that the one emergency light between the hallway and the flex room is not functioning when tested
Corrective Action(s): Ensure all equipment is inspected regularly
Date to be Corrected: Dec 1, 2021
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: Review of the eMAR found that 1 PIC had medication that was not on the eMAR and was not monitored in any fashion. this is the self administered medication
Corrective Action(s): Ensure all medications are documented in the PIC's MAR
Date to be Corrected: Dec 6, 2021
MEDICATION: 36140 - RCR s.70(4)(b) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (b) included in the care plan of the person in care.
Observation: 1 person in care self administers medication but there is no record of a self administration plan in the PICs care plan. LO spoke to the health and wellness coach (LPN) who handles the agencies medication review systems. self admin plans will be created for all PIC's through out the agency for PIC's who self administer
Corrective Action(s): Ensure there is a plan for self administration in the PICs care plan
Date to be Corrected: Dec 6 2021
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