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 cement retaining wall in the back yard is falling down in a few places and is creating slipping and tripping hazard
The walls and baseboards in the tv room, front entrance and sitting room have paint missing and holes in the dry wall
2 lights in the downstairs living room and eating area are damaged 1 missing bulbs, 1 hanging (corrected during inspection)
Upstairs bathroom cupboard doors are very worn and wood is showing through
Window sill in the front bedroom upstairs has chipping paint
Bottom of the fridge in the kitchen missing the bottom cover
Corrective Action(s): ensure rooms and common areas are maintained in a good state of repair
Date to be Corrected: November 1, 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: The patio and deck and stairs in the back yard needs to be cleaned as there is moss and dirt on many of the surfaces
Carpets in upstairs rooms appear stained and dirty
Corrective Action(s): Ensure that all rooms and common areas are maintained in a safe and clean condition
Date to be Corrected: November 1,2018
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: Cleaning agents were stored under the kitchen sink and in the utilities closet in an unsecured area
Corrective Action(s): Ensure cleaning agents are stored in safe, secure and adequate storage areas
Date to be Corrected: October 8, 2018
STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: In conversation with the manager it was explained that the staff evaluations have not been completed for all staff at this time. As per the manager these are to be completed as soon as possible
Corrective Action(s): Ensure that performance evaluations are completed regularly to ensure employees demonstrate the competence required for the duties they have been assigned
Date to be Corrected: November 5, 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: Although there is a system in place for monitoring medications and medication double sign off checks are in place, it was noted that on one MAR there was 6 missing responses on the nurses notes for PRN’s and on another MAR there was 2 missing responses on the nurses notes for PRN’’s
Corrective Action(s): Ensure staff are implementing facility and MSAC policy in regards to the medication administration system
Date to be Corrected: October 15, 2018
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