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: Inspection of facility found one recliner chair where the headrest fabric was ripped, creating a 5 inch round hole where the stuffing was exposed.
Corrective Action(s): Ensure that all furniture for use by persons in care are maintained in a good state of repair.
Date to be Corrected: October 1, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31310 - RCR s.22(2) - A licensee must ensure that emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency.
Observation: Review of the emergency exits found the following:
-the two exits in the laundry room were blocked, one by a mop with bucket and the other was blocked by a shop-vac and other stored items
-the front door exit locked was broken and not able to be unlocked
It was also observed that one outside emergency exit pathway was blocked by blackberry bushes and was impassable.
Corrective Action(s): Ensure that all emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency.
Date to be Corrected: October 1, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31590 - RCR s.30(b) - A licensee must ensure that all bathrooms have (b) slip resistant material on the bottom of each bathtub and shower.
Observation: Inspection of the bathroom found that the bath tub did not have a slip resistant material on the bottom of the tub.
Corrective Action(s): Ensure that the bathtub used by persons in care, has slip resistant material on the bottom of the bathtub.
Date to be Corrected: October 1, 2018
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: Review of the medications and MAR found the following:
- a medication was initialed as dispensed during the day (before 11:00 AM) when it is a 20:00 medication
- a medication review found that a medication for 20:00 was missing
- it appears that the medication initialed as dispensed at the wrong time of day, was initialed in the MAR under another medication name (as per the medication count)
- it appears that staff were unaware of the medication error and that there was no internal incident report completed
Corrective Action(s): Ensure that all employee comply with the policies and procedures of the medication safety and advisory committe.
Date to be Corrected: October 1, 2018
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: Review of 1 of 3 persons in care plans found that it was last reviewed in 2016. Discussion with the staff determined that the person in care's care plan is consistent with his current needs, preferences, and is compatible with the abilities of the person in care.
Corrective Action(s): Ensure that care plans are reviewed each year to ensure it continues to meet the need and preferences of the person in care.
Date to be Corrected: October 1, 2018
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