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 facility found:
-Bathroom walls in the shower room has damage to paint and drywall
-Chipped porcelain sinks in the staff/PIC bathroom
-Bathroom cupbaords are worn to the wood
-Wall behind the kitchen sink has peeling paint and drywall damage from water
-Walls in the TV room have damage from the wheelchairs to the corners
Corrective Action(s): Ensure all rooms and commons areas are maintained in a good state of repair
Date to be Corrected: Dec 7 2021
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: During a review of the PRN protocols it was noted that the last review for two was in 2019, as these are part of the care plan they are required to be reviewed yearly
Corrective Action(s): Ensure PRN protocols are reviewed at minimum 1 time per year
Date to be Corrected: Dec 7 2021
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Inspection of the bathroom cupboards found that there were personal hygiene products stored in the cupboard that were unlabeled
Corrective Action(s): Ensure that all personal products that are stored in a common area are separated and labeled with the PIC's name
Date to be Corrected: Dec 7 2021
MEDICATION: 36150 - RCR s.71(a) - A licensee must ensure that (a) employees do not make handwritten changes to the directions for use of a medication on the medication container or package
Observation: It was observed in the review of the MAR that there were some hand written directions for medication start and stopage times, highlighted and drawn boxes for specific days when a medication is to be given
Corrective Action(s): Ensure there are no written changes to the directions for the medications on the MAR
Date to be Corrected: Dec 7, 2021
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