PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31820 - RCR s.36(1)(c) - A licensee must provide outside activity areas that have (c) comfortable seating including a reasonable amount of shelter from sun and inclement weather.
Observation: Review of the outdoor space, it was observed that there was no cover from sun and inclement weather for persons in care.
Corrective Action(s): Ensure outdoor activity areas include a reasonable amount of shelter from sun and inclement weather.
Date to be Corrected: May 9, 2019
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: 1 of 4 staff files reviewed, determined a performance review was not completed.
Corrective Action(s): Ensure performance reviews are completed to ensure that staff meet the requirements of this regulation.
Date to be Corrected: May 9, 2019
STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: Confirmation of drills for emergency planning could not be located and confirmed by staff that they were not conducted on a regular basis.
Corrective Action(s): Ensure each employee is trained in the implementation of the emergency procedure and any equipment noted in the plan.
Date to be Corrected: May 9, 2019
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: Review of emergency plans, it was determined that an emergency menu was not in place. Updates were also required for various aspects of the plan.
Corrective Action(s): Ensure plans are in place to prepare for,mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Date to be Corrected: May 9, 2019
NUTRITION AND FOOD SERVICES: 37060 - RCR s.62(2)(c)(ii) - A licensee must ensure that each menu provides (c) a variety of foods, taking into consideration (ii) the food preferences and cultural background of the persons in care.
Observation: Review of dietician notes and likes and dislikes documented, one menu item had not been changed since identified in December 2018.
Corrective Action(s): Ensure menu items take into account the food preferences of the persons in care.
Date to be Corrected: May 9, 2019
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 was no menu audits to assist in determining needs are being met as per the Canada's Food Guide. It was confirmed the dietician does not complete these.
Corrective Action(s): Ensure menu audits are completed to confirm persons in care receive adequate food to meet their personal nutritional needs as per the Canada Food Guide.
Date to be Corrected: May 9, 2019
RECORDS AND REPORTING: 39160 - RCR s.78(1)(d) - A licensee must keep, for each person in care, a record showing the following information: (d) information by which the person in care may be described or identified in an emergency, including a photograph.
Observation: Review of person in care records, and emergency plans, persons in care did not have photographs in place to identify them should an emergency occur.
Corrective Action(s): Ensure information, including a photograph is part of identification in an emergency for each person in care.
Date to be Corrected: May 9, 2019
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: Review of 6 care plans, it was determined that care plans required additional detailed plans to guide staff to ensure care is provided based on needs and preferences. In addition, the care plans included information that was inconsistent and not completed fully in some areas.
Corrective Action(s): Ensure care plans are developed fully for each person in care.
Date to be Corrected: May 9, 2019
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