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: Hot water was measured at 52 degrees Celsius.
Corrective Action(s): Please provide a plan that will ensure that water temperatures are monitored to ensure compliance.
Date to be Corrected: July 27, 2107
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: A restraint strap attached to the pull-down arm rest beside the toilet in the back bathroom was observed to be dangling and wrapped around the toilet scrub brush. This is a hygiene hazard in the event the restraint is used. Staff reported that the restraint is never used and the restraint was removed from the arm rest.
Corrective Action(s): Corrected during inspection
Date to be Corrected: Aug. 3, 2017
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31750 - RCR s.35(1)(b) - A licensee must provide the following appropriately furnished and equipped areas: (b) safe and secure locations for medications and the records of persons in care.
Observation: Medication cupboard observed with the key in the lock, when the door was pulled it opened. the door was not locked.
Corrective Action(s): Please provide a sustainable plan that will ensure that as per the Medication storage policy, the medications are always locked in the cupboard.
Date to be Corrected: Aug. 3, 2017
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: A hazardous windshield washer solution and Raid Ant Killer were observed in an unlocked cupboard in the laundry room.
Corrective Action(s): Please provide a plan that will ensure that all hazardous products are identified and stored securely
Date to be Corrected: Aug. 3, 2017
STAFFING: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: Two employees were observed to have outdated performance reviews.
Corrective Action(s): Please provide a sustainable plan to ensure that performance reviews are completed in the time frame that is consistent with the Licensee policy.
Date to be Corrected: Aug. 3, 2017
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: The Licensee policy for medication administration of PRN medications specifically directs staff to record the "results" of their decision to administer a PRN. The results were observed in several instances to either not be written or stated "administered". Such notations do not describe the success or failure of the staff's decision to administer the medication to the PIC and could be interpreted as a medication error.
Corrective Action(s): Please provide a sustainable plan that will be monitored to ensure that the policy to record the results of the PRN administration is implemented and results are recorded appropriately
Date to be Corrected: Aug. 3, 2017
CARE AND/OR SUPERVISION: 34090 - RCR s.50(1) - A licensee must regularly monitor the health and safety of each person in care to determine whether the needs of the person in care continue to be met.
Observation: One PIC was observed to have had a significant unintended weight loss, as per records (35 lbs.). the PIC had transferred from another facility. The admission weight and height (had lost 1 inch) were not accurately identified on the profile page in share vision, and the photograph was not current enough to be of assistance if the person were missing.
Corrective Action(s): Please provide a plan that will ensure that the monitoring systems in place for each PIC are accurate in order to provide referral to the appropriate health care practitioners should the need arise or to use in the event the PIC is missing.
Date to be Corrected: Aug. 3, 2017
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Products in the fridge were observed not to be labelled.
Corrective Action(s): Please ensure provide a plan that will ensure that Food Safe principles are applied
Date to be Corrected: Aug. 3, 2017
RECORDS AND REPORTING: 39340 - RCR s.84(a) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (a) the type or nature of the restraint used.
Observation: Approval for restraint was not observed in the careplan of a PIC who is wheelchair dependent.
Corrective Action(s): Please provide a plan that will ensure that all residents who are restrained have appropriate documentation that is reviewed regularly.
Date to be Corrected: Aug. 3, 2017
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