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: Dresser x 2 with knobs missing and one bathroom drawer, also one dresser with moisture rings across the entire back of the top surface.
Corrective Action(s): Please ensure that the furniture is appropriately maintained to support the dignity of the individuals.
Date to be Corrected: Jan 4, 2018
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 window sill in the ensuite of the master bedroom is damaged from moisture on 3 of four surfaces of the window surround. The are several areas of paint damage abutting the door casing to the same bathroom.
Corrective Action(s): Please provide a plan that will ensure that damage is corrected in a timely manner before the arrival of a new resident into the room.
Date to be Corrected: Jan. 4, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: A downstairs bedroom was observed to be heated with an electrical baseboard heater as well as a forced air vent in the ceiling. The baseboard heater was positioned behind the length of a single bed. The bedding was in contact with the heater. Also there were canvases of oil like paintings sitting on the radiator. As well there was a small over filled desk at the foot of the bed that blocked the circulation of the heat. This represents a fire hazard and requires immediate attention.
Corrective Action(s): Please ensure that heat producing appliances are not in contact with flammable products.
Date to be Corrected: Dec.. 18, 2017
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31520 - RCR s.28(1) - A licensee must ensure that each bedroom has a window that provides natural light to the bedroom, with coverings that block out light and protect the privacy of the occupant.
Observation: A PIC bedroom was observed to have venetian blinds but no curtains over the window. The bedroom is on the ground floor, slightly lower than grade level, and the window is in direct vision from a window of the house across from it. The manager states the resident of the room is not likely to remember to tip the blinds for privacy while dressing. There is hardware in place for curtains for this window, the manager agreed it would be more optimal protection of privacy to install curtains to this window.
Corrective Action(s): Please provide a plan that will ensure the PIC has privacy while changing.
Date to be Corrected: Jan. 4, 2018
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 are not being conducted monthly. The record of fire drills shows no drills since September. The facility policy states monthly fire and earth quake training. The remainder of the year was not reviewed. A Pepsi bottle was observed to be filled with water. There was no expiry date and there was dust on the shoulders of the bottle. The Emergency water supplies are dated with the date they were changed, not the date they need to be changed as per policy.
Corrective Action(s): Please ensure that Emergency training and use of equipment is consistent with the licensee policy by providing a plan that will ensure that this occurs and providing a staff nominated to monitor that the training is completed.
Date to be Corrected: Jan. 4, 2018
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: One example of PRN medication was observed to be given regularly, a topical cream. The result of the treatment is not being documented on the back of the MAR as per medication policy.
Corrective Action(s): Please provide a plan that will ensure that, as per policy, the results of the use of a PRN medication are documented in order to ensure that medications that are not effective are brought to the attention of the pharmacist and the doctor.
Date to be Corrected: Jan. 4, 2018
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: The Immunization record of the one of three PICs whose file was audited did not show evidence of compliance with the provincial immunization and TB program. The TB status was present.
Corrective Action(s): Please provide a plan that will ensure that evidence for all of the residents of immunization and Tb status is present for inspection. This contravention is a repeat from the 2015 inspection.
Date to be Corrected: Jan. 4, 2018
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: Many personal care products were observed throughout the house that were not labelled for the user.
Corrective Action(s): Please ensure that all personal care products, shampoos, lotions manicure utensils are labelled with the user's name.
Date to be Corrected: January 4, 2018
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