PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Maxiumum water temperature throughout the facility found to range from 64.9 degrees Celsius to 65.6 degrees Celsius.
Corrective Action(s): Ensure all water accessible to persons in care, from any source, is not heated to more than 49 degrees Celsius.
Date to be Corrected: July 22, 2021 (immediate action needed)
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: The stove top had rust, and only two burners were working. The faucet handle in the main bathroom spun freely and required repair.
Corrective Action(s): Ensure all furniture and equipment is in a good state of repair.
Date to be Corrected: September 15, 2021
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 physical facility found the following:
-The front door had several broken and/or missing tiles on the step, creating an uneven surface at the entry.
-Most kitchen cupboards had worn surfaces and discoloration.
-The kitchen linoleum was pulling away from where the floor met the cupboards.
-In the first bathroom, the thermostat had no cover and the humidity controls cover was loose.
-There was missing trim behind the bathroom door in the first bathroom.
-A second bathroom's wash basin had a 10cm in diameter rusted area and its shower did not have a shower head.
-The lower part of the garage door had peeling paint.
Corrective Action(s): Ensure all rooms and common areas are in a good state of repair.
Date to be Corrected: October 15, 2021
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: Yellow/brown coloring was observed along the bottom and edges of the bathroom bathtub and a pink film along its caulking and soap dishes. One person in care's bedroom had three areas of discoloration along the edges of the ceiling, with one measuring approximately 45 cm in length and 15 cm width.
Corrective Action(s): Ensure all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: August 15, 2021
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: A mop and bucket blocked an emergency exit.
Corrective Action(s): Ensure emergency exits are not obstructed or secured.
Date to be Corrected: July 22, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: The kitchen cupboard containing cleaning agents was unlocked and accessible to persons in care.
Corrective Action(s): Ensure cupboards and other storage areas housing cleaning agents, chemical products and other hazardous materials are not accessible to persons in care.
Date to be Corrected: July 22, 2021
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: The licensee's medication policies and procedures required that a staff initialed for medications administered and a second staff checked and initialed that the administering staff had completed the medication pass as required. This process was inconsistently completed.
Corrective Action(s): Ensure staff implement medication policies and procedures.
Date to be Corrected: August 15, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: A food storage area had an unlabeled container with food inside, and an open food package in the freezer.
Corrective Action(s): Ensure all food is safely stored.
Date to be Corrected: August 15, 2021
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: Four expired jars of medicated creams and two bottles of expired medicated shampoos were stored in the medicine cabinet.
Corrective Action(s): Ensure expired medications are returned to the pharmacist.
Date to be Corrected: August 11, 2021
RECORDS AND REPORTING: 39190 - RCR s.78(2)(a) - A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care.
Observation: There was no evidence that a person in care was administered prescribed medcations during a 24-hour period in the month of July 2021.
Corrective Action(s): Ensure all medication administration records indicate medications having been administered or the reason why they were not administered.
Date to be Corrected: August 15, 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: A record of menu substitutions was inconsistently being recorded, such as December 25, 2020 where a turkey (a substitute) was served but not recorded on the menu substitution record.
Corrective Action(s): Ensure there is a record kept of menu substitutions.
Date to be Corrected: August 31, 2021
RECORDS AND REPORTING: 39610 - RCR s.91(2)(b) - In respect of a record referred to in this regulation, a licensee must (b) keep a record other than one referred to in paragraph (a) in a place from which it can be retrieved within a reasonable time, on request.
Observation: Medication Advisory and Safety Committee minutes and medication room inspection record were not available for review at time of this inspection, nor in a reasonable time that was given after.
Corrective Action(s): Ensure records are kept in a place where they can be retrieved from within a reasonable time, upon request.
Date to be Corrected: September 30, 2021
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