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 (CORRECTED DURING INSPECTION): The hot water was measured to be 59.5°C in the upstairs main bathroom, 60.5°C in the tub located in a person in care's bathroom, and 59.5°C at a common sink located on the lower floor. Management lowered the temperature and will have the regulator adjusted so as to maintain it at or below 49.0°C.
Corrective Action(s): Corrected at time of inspection.
Date to be Corrected: Corrected at time of inspection.
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: Upon inspection of rooms and common areas, the following was observed:
- Minor paint scuffs and one elongated scrape to the drywall and measuring approximately 2cm x 3.5cm were located on the downstairs bathroom wall behind the sink.
- An patch of wall from a previous wall repair approximately 20cm x 45cm and located behind a large chair in the front room required painting.
- Baseboards in a person in care's bedroom were pulling away from the wall and the bedroom walls had putty marks that required paint.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: May 24, 2021
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: A fire drill was not conducted for the month of April 2021. The licensee's policy on emergency planning, including fire safety, states that fire drills are to be conducted monthly.
Corrective Action(s): Ensure fire drills are conducted on a monthly basis to ensure that each employee is trained in the implementation of the fire safety plan, as per licensee policy.
Date to be Corrected: May 24, 2021
CARE AND/OR SUPERVISION: 34570 - RCR s.75(3)(b) - If a restraint is used under section 74(1)(b) and the use of the restraint continues either continuously or intermittently for more than 24 hours, a licensee must (b) as part of the reassessment, consult, to the extent reasonably practical, with the persons who agreed to the use of the restraint.
Observation: A person in care's medical practitioner was not consulted during the annual reassessment for the use of restraint(s) included in the PICs behaviour safety plan.
Corrective Action(s): Ensure reassessment of the use of a continuous or intermittent restraint includes consultation with the persons who agreed to the use of the restraint and that consultation is documented.
Date to be Corrected: May 24, 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: Upon review of food storage areas, the following was observed:
- The chest freezer contained 2 items that had not been labelled and dated.
- 5 dry goods items in the kitchen had not been labelled to identify the contents or the date of expiry.
- The freezer in the kitchen contained a bag of individually packaged items that had not been labelled to identify the contents or the date of storage.
Corrective Action(s): Ensure all food items are safely stored.
Date to be Corrected: May 24, 2021
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: 4 of 4 PIC files were reviewed and it was observed that the weight of 1 PIC had not been recorded for January 2021.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: May 24, 2021
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