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: The outer window wooden borders are bare and cracking in multiple areas.
Corrective Action(s): Please ensure that all windows are maintained in a safe and clean condition.
Date to be Corrected: January 30 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: During inspection, the following was noted:
- As per agency policy, fire drills must be completed monthly. In 2017, the facility only completed 9 out of 12 fire drills.
- As per agency policy, emergency preparedness must be maintained. 2 items within the facility first aid kit were expired (alcohol wipes expired in 2001, dressings expired in 2015).
Corrective Action(s): Please ensure that all policies are implemented by staff.
Date to be Corrected: January 30 2018
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: A review of the facility nutrition program found that all audits within the meals and more manual had not been completed since 2015.
Corrective Action(s): Please take steps to ensure that adequate food is being provided to meet the individual nutritional needs of the PIC's and that the nutritional care plan is being taken into consideration..
Date to be Corrected: February 15 2018
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation (CORRECTED DURING INSPECTION): A review of 3 PIC's binders found that none had consent in writing to call an ambulance or medical practitioner in the case of an emergency.
Corrective Action(s): Please ensure that consent is kept in writing to call an ambulance or medical practitioner in an emergency.
Date to be Corrected: January 8 2018
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