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: During inspection of the physical facility, the following was noted:
o Leather couches were noted to be splitting in certain places, and extensive wear was noted to several of the seat cushions.
Corrective Action(s): Please ensure that all furniture used by persons in care are maintained in a good state of repair.
Date to be Corrected: Please provide a plan as to how the wear and tear to the couch services will be addressed by September 30, 2017.
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: During the physical inspection, the following was noted:
o A hole was noted to the door of the medication/office room, and 2 other holes to walls,
o The exterior hand rail that runs along the back driveway was noted to unstable not secure,
o Several boards were missing from the south facing fence.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: September 30, 2017
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: It was noted that persons in care do use the laundry facilities. A slip resistant surface or mat was not located in the laundry room.
Corrective Action(s): Please ensure that the laundry facility has a slip resistant floor surface.
Date to be Corrected: September 30, 2017
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31820 - RCR s.36(1)(c) - A licensee must provide outside activity areas that have (c) comfortable seating including a reasonable amount of shelter from sun and inclement weather.
Observation: Inspection of the outdoor areas did not observe any comfortable seating for persons in care.
Corrective Action(s): Please ensure comfortable seating is available to persons in care in the outdoor areas.
Date to be Corrected: September 30, 2017
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: In review of the Medication Administration Records (MAR), 5 examples of missed initials were noted. It was also noted that several PRN's that have been administered were not documented on the back page of the MAR and results of the PRN were not noted.
Corrective Action(s): Please ensure all employees comply with the policies and procedures related to medications.
Date to be Corrected: September 30, 2017
CARE AND/OR SUPERVISION: 34630 - RCR s.81(3)(b) - A care plan must include all of the following: (b) an oral health care plan.
Observation: In review of 2 care plans, the plans did not address oral care needs of the clients.
Corrective Action(s): Please ensure all clients have a plan for oral care.
Date to be Corrected: September 30, 2017
CARE AND/OR SUPERVISION: 34640 - RCR s.81(3)(c)(i) - A care plan must include all of the following: (c) a nutrition plan that (i) assesses a person in care's nutrition status.
Observation: In review of 2 client care plans, a nutrition care plan was not developed and implemented.
Corrective Action(s): Please ensure all clients have nutrition care plans developed on admission, and nutritional status is assessed.
Date to be Corrected: September 30, 2017
CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: In review of the care plans for 2 clients, a recreation or leisure plan was not developed.
Corrective Action(s): Please ensure all clients have care plans that address their recreation/leisure needs.
Date to be Corrected: September 30, 2017
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