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: Inspection of the women's bathroom found that there was rust around the bottom of the faucet where it contacts the sink basin. There was missing caulking around the women's toilets where the toilets contact the floor. The men's bathroom sink counter, which is green in colour was discolored and worn showing large white patches of counter
Inspection of one room found that a sheet was being used for a window covering. Discussion with the Manager determined that the person in care in frequently removing the window coverings ex. blinds, curtains and breaking them. The Manager is in the process of replacing them and will continue to replace them when are broken.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: July 5, 2016
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: A review of the Medication Administration Record (MAR) for 5 persons in care found the following:
-2 out of 4 PRN's administered for 1 person in care did not have the PRN effectiveness recorded
-2 out of 9 PRN's administered for 1 person in care did not have the PRN effectiveness recorded
Corrective Action(s): Ensure that all policies and procedures are implemented by employees.
Date to be Corrected: July 5, 2016
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: A review of 5 person in care's (PIC) care plans, found that 2 of the 5 care plans had not been reviewed since April 2015 and May 2015.
Corrective Action(s): Ensure that each care plan is reviewed at least once each year to ensure that it continues to meet the needs and preferences and is compatible with the abilities of the person in care who is the subject of the care plan.
Date to be Corrected: July 5, 2016
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: A random review of the medications found 1 prescribed medication that had expired.
Corrective Action(s): Ensure that all person in care's medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Date to be Corrected: July 5, 2016
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