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: Hot water in the recreation area accessible to residents measured over 50.5 degrees Celsius. The water temperature was adjusted to below 49.0 degrees Celsius before the completion of this inspection.
Corrective Action(s): Please provide a plan that will ensure that there is regular monitoring of the hot water system to ensure that residents do not have access to water higher than 49.0 degrees Celsius.
Date to be Corrected: October 27, 2017
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: The laminate counter application to the side of the vanity in room 309 was seen to be loose for approximately 5 inches. This makes sanitation of the area difficult and poses a risk to catch the clothes of residents.
Corrective Action(s): Please provide a plan that ensures that the facility is monitored for the state of repair/maintenance in all areas
Date to be Corrected: October 27, 2017
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31750 - RCR s.35(1)(b) - A licensee must provide the following appropriately furnished and equipped areas: (b) safe and secure locations for medications and the records of persons in care.
Observation: A resident newly admitted for respite was seen to have Fucidin Cream, sennosides and Atrovent at the bedside and in the washroom.
Corrective Action(s): Please provide a plan that will ensure that all residents, including short term residents',medications are stored in a safe secure location.
Date to be Corrected: October 27, 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: Several examples of PRN medications were observed that did not contain documentation of the "results" of the administration of the medication as per PRN Administration Policy.
Corrective Action(s): Please provide a plan that will ensure that for medications administered as a result of the nurses' judgement, will reflect the results of that administration as well as comply with the MSAC Policy.
Date to be Corrected: Oct. 27, 2017
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: Of 2 resident records reviewed, one did not have evidence of immunization status.
Corrective Action(s): Please provide a plan that will ensure that as per the regulation quoted above, that all persons admitted to the facility comply with the Province's Immunization and tuberculosis control programs.
Date to be Corrected: Oct. 27, 2017
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