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: An inspection of the facility grounds found that a shed in the backyard, which is used to store facility equipment, has a leaky roof (a tarp is currently being used to mitigate leakage) that is in need of repair.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: September 1, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation (CORRECTED DURING INSPECTION): An inspection of the facility's medications found that old and expired medications, which were to be returned to the pharmacy for disposal, were being stored outside of the medication room in an unlocked cabinet in a hall closet.
Corrective Action(s): Ensure that all medications are safely and securely stored.
Date to be Corrected: August 4, 2021
CARE AND/OR SUPERVISION: 34080 - RCR s.49(3) - A licensee must assess each person in care on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.
Observation: A review of admission records found that no persons in care had been assessed on admission to determine the risk that the persons in care may leave the community care facility without notification of an employee,
Corrective Action(s): Ensure that persons in care on admission are assessed to determine the risk that they may leave the facility without notification of an employee.
Date to be Corrected: August 18, 2021
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: One person in care was observed to be using a fall mat; however, the usage of the fall mat was not recorded in the care plan of the person in care.
Corrective Action(s): Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Date to be Corrected: August 11, 2021
RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: An inspection of the facility's menus found no evidence that a record of menu substitutions was being kept. Facility management confirmed that a record of menu substitutions was not being kept.
Corrective Action(s): Ensure that a record of menu substitutions is being kept.
Date to be Corrected: August 11, 2021
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