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: During a review of the physical facility, it was noted that the area around the sidewall of the bathtub in the main bathroom was in need of repair where the sidewall met the wall and where the sidewall met the floor. An area of the wall next to the bathtub sidewall also had chipped paint. During the inspection, the manager stated that she is aware of the need for repair; however, there is no current plan in place to address the repair.
Corrective Action(s): Please ensure rooms and common areas of the facility are maintained in a good state of repair.
Date to be Corrected: February 28, 2021
POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation: During review of the emergency supply kit and emergency folder, the following was noted:
- The emergency supply kit did not contain a sufficient supply of water to meet the needs of each PIC and staff in the event of an emergency
- The emergency folder did not contain medication information for 1 PIC
- The management contact information in the emergency contact information was outdated
Corrective Action(s): Please ensure that emergency supplies are adequate and emergency information is current so as to address the needs of persons in care in the event of an emergency.
Date to be Corrected: February 28, 2021
POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: During review of the medication binder, it was noted that the medication safety and advisory committee has not attended the facility in over 1 year to review the training and orientation program for employees who store, handle, or administer medications to persons in care or review the policies and procedures in respect of the safe and effective storage, handling and administration of the persons in care's medications.
Corrective Action(s): Please ensure the medication safety and advisory committee attends the facility as required to review training and orientation programs for employees and review the policies and procedures in respect of the safe and effective storage, handling and administration of the person in care's medication.
Date to be Corrected: February 28, 2021
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