PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation (CORRECTED DURING INSPECTION): Inspection of the facility rooms found fall mats that had noticeable stains that were not easily removed by the daily cleaning staff. Discussion with maintenance determined that fall mats will be thoroughly cleaned with a heavy cleaner when the PIC is discharged. Further discussion with maintenance determined that long term PIC's fall mats only get a daily wipe.
Corrective Action(s): Ensure that there is a plan in place to clean well soiled fall mats for PIC's that are long term residents.
Date to be Corrected: CORRECTED DURING INSPECTION
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: Review of the kitchen fire extinguisher found that it was expired as of January 14, 2017.
Corrective Action(s): Ensure that all emergency equipment are inspected and maintained on a regular basis.
Date to be Corrected: April 16, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31850 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation (CORRECTED DURING INSPECTION): Inspection of all eight floors of the facility found that three floors did not have a weekly menu posted in the dining room.
Corrective Action(s): Ensure that floor has a weekly menu prominently placed in each dining area.
Date to be Corrected: CORRECTED DURING INSPECTION
STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Review of employee records found that one employee had completed a tuberculosis test (TB) and then required to complete an x-ray. The x-ray and results of the further testing were not in the employee file.
Corrective Action(s): Ensure that employee records are complete.
Date to be Corrected: April 16, 2018
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: Discussion with the Human Resources (HR) staff and review of the employee files determined that all facility employees are in need of their 2 year performance evaluations. It is noted that there has been a change in Management staff and that this has caused the delay in completing the performance evaluations.
Corrective Action(s): Ensure that performance reviews are regularly completed to ensure that employees continue to meet the requirement of this regulation.
Date to be Corrected: April 16, 2018
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 the hard copy of the policies and procedures that is kept on each floor is dated March 2016.
Corrective Action(s): Ensure that all policies and procedures are reviewed and if necessary revised once each year.
Date to be Corrected: April 16, 2018
CARE AND/OR SUPERVISION: 34890 - RCR s.83(4)(b) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (b) immediately seek the advice of a health care provider if the person in care has experienced, unintentionally, a significant change in weight,
Observation: Review of 1 of 8 care plans for persons in care (PIC) found that one PIC had a noticeable weight decrease. The weight was flagged by the care system but no documentation to confirm that the PIC had seen a health care provider for the weight loss. Discussion with the Registered Dietician (RD) confirmed that they were aware of the weight loss but it was not a concern.
Corrective Action(s): Ensure that if there is a significant change in a PIC's weight that there is documentation to confirm that the PIC has seen a health care provider for this significant change..
Date to be Corrected: April 16, 2018
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Review of 3 of 16 tub rooms found hairbrushes, combs, and deodorants that were not labelled and it could not be determined if they were being used for one individual PIC or were universally used for the PIC's on the floor.
Corrective Action(s): Ensure that items for individual PIC use are clearly marked/identified to ensure the health and hygiene of persons in care.
Date to be Corrected: April 16, 2018
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 1 of 8 care plan records found that one person in care had no weights recorded for four consecutive months.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: April 16, 2018
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Review of the food services documentation found that satisfaction surveys for persons in care had not been completed since November/December 2015. Discussion with the Registered Dietician indicated that this is overdue and needs to be completed. It was also discussed that there is a plan in place to complete the surveys this year.
Corrective Action(s): Ensure that all food service documentation and results of monitoring food services and nutrition care are completed.
Date to be Corrected: April 16, 2018
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