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: The corner protectors on doorway moldings and hallway corners are torn and bent;
- paint on hallway walls and bathroom walls is chipped worn and bruised from wheelchairs;
- both bathroom counters are worn through the countertop design
-the kitchen linoleum flooring is missing the bonding agent for an approximately 5 foot length in front of the sink. The edges are curled and can represent a trip hazard and not easily cleaned.
Corrective Action(s): Please ensure that maintenance is maintained in the facility by providing a plan to maintain the above noted issues.
Date to be Corrected: Dec. 19, 2016
STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Employee performance review x1 was observed to be scheduled for Feb. 2016, but has not been completed.
Corrective Action(s): Please ensure that all performance reviews are conducted annually or as per Licensee policy to ensure compliance with above regulation.
Date to be Corrected: Dec. 19, 2016
STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: Fire Drills were missing for Feb. and July. This facility completes multiple kinds of disaster drills every month.
Corrective Action(s): Please provide a plan to ensure that staff are trained in the implementation of the fire drill plan on a regular basis.
Date to be Corrected: Dec. 19, 2016
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: A basket of unlabelled sunscreen was observed in the secondary medication cupboard in the laundry room. There is a DIN number on the product and therefore requires labelling by the pharmacist.
Corrective Action(s): Please ensure that all products containing a DIN number are ordered by the physician and labelled by the pharmacist.
Date to be Corrected: Dec. 19, 2016
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: The substitution list was observed in a Menu binder. The last entry was Oct. 19, 2016. The manager states there was a pizza night on Grey Cup day, that was not entered on the substitution list.
Corrective Action(s): Please provide a plan that will ensure that substitutions are recorded appropriately and in a timely manner. It may be of assistance to maintain the substitution list in an easily accessible location.
Date to be Corrected: Dec. 19, 2016
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