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: Hot water temperatures were tested in both the women's and men's washroom. The temperature in both washrooms were recorded as 54.2'Celsius
Corrective Action(s): A licensee must ensure water accessible to persons in care does not exceed more than 49'Celsius
Date to be Corrected: October 9 2023
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: Two person's in care (PIC) bedrooms were viewed, licensing observed two pieces of furniture that had broken doors, and another piece of furniture that had missing handles with screws exposed.
Corrective Action(s): A licensee must ensure that all furniture and equipment for use by persons in care is maintained in a good state of repair
Date to be Corrected: October 9 2023
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 review of the PIC bathrooms, it was observed that two of the men's bathrooms had a very strong odour present, a wooden panel supporting the hand rail was chipping and appeared to be rotting in the tub room, and the shower curtain was not maintained in a clean manager.
Corrective Action(s): A licensee must ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: October 9 2023
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31590 - RCR s.30(b) - A licensee must ensure that all bathrooms have (b) slip resistant material on the bottom of each bathtub and shower.
Observation: Upon review of the facility's tub rooms, no slip resistant material was observed in any of the bathtubs or showers.
Corrective Action(s): A licensee must ensure that all bathrooms have slip resistant materials on the bottom of each bathtub and shower
Date to be Corrected: October 9 2023
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 (CORRECTED DURING INSPECTION): During the inspection it was observed that two designated cupboards to store cleaning agents were left unlocked. Bleach was accessible in an unlocked cupboard in the laundry room.
Corrective Action(s): A licensee must provide a secure, safe and adequate storage for cleaning agents.
Date to be Corrected: October 9 2023
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Upon review of the staffing files, it was observed that 4 out of 5 staff have not received their performance review annually as per facility's polices
Corrective Action(s): A licensee must ensure that the performance of each employee is reviewed regularly and as per the facility's own polices.
Date to be Corrected: October 9 2023
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Upon review of the medication records, the effectiveness of the PRN's being administered to the persons in care are not being recorded
Corrective Action(s): A licensee must ensure that all employees comply with polices and procedures of the Medication Safety and Advisory Committee.
Date to be Corrected: October 9 2023
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Upon review of the facility's policies, it was confirmed that only two had been reviewed within the last 2 years. The date recorded for the review was 2021.
Corrective Action(s): A licensee must review and revise the policies and procedures, as necessary, at least once per year.
Date to be Corrected: October 9 2023
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: Upon review of the PIC's medical records, it was observed that a plan was meant to be reassessed in August 2023, it was confirmed the plan was not reviewed on this date or after.
Corrective Action(s): A licensee must ensure that the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Date to be Corrected: October 9 2023
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 the facility's freezer's, it was observed that food items have been stored without being dated and labelled. I the food storage room, dried items in large plastic containers were not labelled and dated as per the facility's food safety policies.
Corrective Action(s): A licensee must ensure that all food is safely stored and handled
Date to be Corrected: October 9 2023
MEDICATION: 36130 - RCR s.70(4)(a) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (a) approved by the medication safety and advisory committee and the medical practitioner or nurse practitioner who prescribed or ordered the medication.
Observation: Upon review of the medication records, it was observed that a Person in Care self-medicating does not have an approved plan in place to self medicate. .
Corrective Action(s): A licensee may permit a person in care to self-administer medication if a plan is approved by medication safety and advisory committee and the medical practitioner who prescribed the medication
Date to be Corrected: October 4 2023
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