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: Two person in care bathrooms did not have a cover over the water shut off valve, leaving exposed insulation and drywall.
Corrective Action(s): A licensee must ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31550 - RCR s.29(1)(a) - A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including (a) a safe, secure place in which the person in care may store valuable property.
Observation (CORRECTED DURING INSPECTION): Multiple persons in care do not have access to a secure place to store valuables. Discussion with the manager determined, that the facility is currently providing persons in care with a new bedside table, and locks will be installed on these new tables.
Corrective Action(s): A licensee will provide at no cost to the person in care, bedroom furnishings including a safe and secure place to store valuables. Please submit a plan to licensing to have a secure place for all persons in care to store their valuables.
Date to be Corrected: Corrected before 2nd day of inspection.
STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: Review of 6 staff files found that 1 staff member had a criminal record check through the city police, not the CCRA
Corrective Action(s): Ensure all staff have a criminal record on file through the Criminal Record Review act.
Date to be Corrected:
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 (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Review of 6 staff files found that 2 staff had not had a performance review since January 2018.
Corrective Action(s): Ensure that performance of each employee is reviewed regularly to meet the requirement of this regulation.
Date to be Corrected:
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: Review of emergency supplies and discussion with manager determined to following:
-There was not enough emergency food or water for the 22 persons in care and staff for 72 hours. (Capacity is 25 persons in care)
Corrective Action(s): Ensure there is an emergency plan in place that sets out how persons in care will continue to be cared for in the event of an emergency.
Date to be Corrected:
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: Review of facility policies and discussion with the manager determined that policies last show evidence of review or modification in 2016. The medication policy guiding staff was last updated in 2011 and does not show evidence of annual review.
Corrective Action(s): A licensee must review and if necessary, revise the policies and procedures at least once each year.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation (CORRECTED DURING INSPECTION): The care plan for one person in care (PIC) states that the PIC has Q30 minute checks in place, when in fact Q60 minute checks have been implemented, the care plan has not been updated. When reviewing the Q60 check log, checks have not been completed at all from March 5th- March 10th.
Corrective Action(s): Licensee must ensure that each care plan is reviewed and if necessary, modified if there is a substantial change in the circumstance of the person in care.
Date to be Corrected: Care plan updated before 2nd day of inspection
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: On review of 5 person in care records, the following was identified:
-one person in care's immunization record was incomplete
-A second person in care's immunization record is incomplete and not signed
Corrective Action(s): Ensure all persons in care admitted to a community care facility comply with the Province's immunization and TB control programs.
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37020 - RCR s.62(1)(b) - A licensee must ensure that a menu, made in accordance with this section, is developed (b) in any other case, for at least each 4 week period.
Observation: Review of menus currently being used identified that one week of the winter menu is: partially written on a piece of paper, partially printed, and snacks being served are written down as they go, and snacks are not listed on the menu at all. Discussion with the manager determined that there is a dietician currently scheduled for March 23rd, 2020 to come into the facility to assist with food and nutrition services.
Corrective Action(s): A licensee must ensure there is a menu developed, for at least each 4 week period.
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Review of the current menu being used determined that on most days of the week the lunch and evening meal only include 2 food groups (ie) fish and chips. The cook reports that a third food group is served for most meals, however it is not recorded on the menu substitutions list. There is a dietitian scheduled to come to the facility March 23, 2020 to assist with development of food and nutrition services.
Corrective Action(s): Ensure for each day, each meal contains at least 3 food groups as described in the Canada food guide.
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Snacks are not listed on the menu being used, the list of snacks being served is recorded each day, however review of snacks being served determined that in most cases only one food group is being served.
Corrective Action(s): Ensure for each day, two snacks are being served, with each snack containing at least two food groups as per Canada's food guide.
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Review of the menu substitution list and discussion with the cook determined that there were not menu substitutions documented between May - December 2019. Some menus substitutions recorded, do not substitute foods from the same food group.
Corrective Action(s): Food substitutions are to be made from the same food group and have a similar nutritional value.
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: Review of food and nutrition documentation, there were no menu audits to assist in determining if person in care's nutritional needs are being met as per the Canada food guide. It was confirmed by the manager that menu audits have not been completed, however a dietician is scheduled to come into the facility to assist in nutritional planning and development on March 23, 2020.
Corrective Action(s): A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's food guide and the person in care's nutrition plan.
Date to be Corrected:
RECORDS AND REPORTING: 39310 - RCR s.81(1) - If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: One person in care was admitted on January 30, 2020 and does not have a care plan in place to guide caregivers in providing care.
Corrective Action(s): A person is admitted to a community care facility for a period of more than 30 days, a licensee must ensure that a care plan is developed within 30 days of admission.
Date to be Corrected:
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: Review of five persons in care from May 2019- February 2020 found that all five persons in care had between 3 -7 months where their weight was not recorded from the 9 months reviewed. The reasons for the weights being missed was not recorded.
Corrective Action(s): Ensure each person in care is weighed at least once each month.
Date to be Corrected:
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