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: 4 staff files were reviewed, one of which was a newly hired staff member. Only 1 staff member had a performance evaluation on file completed in 2019. The facility's Policy is for the job perfomance evaluation to be completed annually.
Corrective Action(s): Please ensure that the facility comply with the Policy of it's annual job performance evaluation.
Date to be Corrected: September 7, 2021
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: The four week menu was reviewed, 4 of the dinner menu and one lunch menu only contained 2 food groups rather than the 3 food groups required.
Corrective Action(s): Please ensure that all the meal contains at least 3 food groups as described in Canada's Food Guide.
Date to be Corrected: August 24, 2021
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: With the exception of 2 snack times in the month, all other snack contained 1 food group as in described in the Canada Food Guide.
Corrective Action(s): Please ensure that snacks include at least 2 food groups.
Date to be Corrected: August 24, 2021
RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: The Facility does not maintain the height and weight of each Person in Care on admission.
Corrective Action(s): The facility had an approved exemption from Dec 1, 2016-Dec 1, 2018 from this requirement. Please ensure the height and weight is recorded for new admissions. The Licensee may apply for an exemption from this requirement which is subject to review and approval by Licensing.
Date to be Corrected: August 19, 2021
RECORDS AND REPORTING: 39200 - RCR s.78(2)(b) - A licensee must keep, for each person in care, a medication administration record showing (b) the date, amount and time at which the medication was administered.
Observation: Review of the Medication Administration Record as well as the Facility's internal Record system, reflected times when medication was signed but not given or given but not signed. The reason such as refusal was not reflected on the MAR.
Corrective Action(s): Please ensure a record of Medication administered is maintained at all times.
Date to be Corrected: August 23, 2021
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: The PIC's have not been weighed monthly. Licensee had an approved exemption from the requirement which expired on December 1, 2018.
Corrective Action(s): The Licensee may apply for an exemption from this requirement, which is subject to review and approval by Licensing.
Date to be Corrected: August 19, 2021
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