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: A tour/walkthrough of all the floors for Terraces at Evergreen and the second building - The Pointe indicated the following, for example:
- On the 4th floor outside the elevator noted alot of black coloured scuff marks along the wooden board near the flooring and dining area.
- On Floor # 7 baseboards near the flooring throughout noted with alot of scuff marks.
- on Floor # 8 there is one section in the ceiling that has been opened up (ceiling tiles removed) and this has been left in this state since approximately December 2020. By the elevator on the wall where the hand sanitizer dispenser is mounted noted with paint peeled off and white colour on the wall.
- Level D3 of "The Pointe" with baseboard near the flooring throughout the care unit with scuff marks. The floor appears soiled in areas and apparently some sections were waxed.
- Level D2 of "The Pointe" with handrails throughout the care unit with the white paint chipped/peeling off.
Corrective Action(s): Please ensure both buildings (Terraces at Evergreen including "The Pointe") are maintained in a good state of repair.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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Observation: A random review of 4 staff files indicated that for 1 staff file the criminal record check is outdated and not current.
Corrective Action(s): Please ensure where required staff have their criminal record check completed through the Ministry for Public Safety and Solicitor General and the documentation is kept on the staff files.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A random review of 4 staff files indicated for two of the staff that the appraisals are not current or noted on the staff files. The Administrator/Manager stated a Human Resources Coordinator has been hired to assist with this work.
Corrective Action(s): Please ensure all staff as required have a performance review on a regular basis.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: In review of the policies and procedures required by the Residential Care Regulation they have not been reviewed and/or revised once a year. For example, Compliments and Concerns policy next review date is November 2020 (Original date February 1, 2019), and Access to Persons in Care original date of July 1, 2016 and next review date is noted as December 1, 2019.
Corrective Action(s): Please ensure all policies and procedures required by the Residential Care Regulation are reviewed and/or revised once a year. For the remainder of the policies and procedures, please ensure there is a system for review and/or revision.
Date to be Corrected: The Administrator/Manager stated the policies and procedures will be reviewed and/or revised by the end of March 31, 2021.
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: A random review of four staff files indicated for one staff file there was not a documented list of the immunizations received by the staff. Community Care Facilities Licensing has a Tuberculosis and Immunization Guideline for staff that the writer has shared with the site previously that can be used which has a standardized immunization form.
Corrective Action(s): Please ensure as required staff have a thoroughly documented listing of immunizations they have received noted on their personnel files.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A review of the care planning system indicated Tuberculosis clearance was not documented for a person in care. In addition, please also ensure immunizations are documented as required for persons in care.
Corrective Action(s): Please ensure Tuberculosis clearance is documented for persons in care as required. Community Care Facilities Licensing has a Tuberculosis and Immunization Guideline for persons in care that can be utilized.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39380 - RCR s.84(e) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (e) the result of any reassessment of the use of the restraint.
Observation: A review of the restraint documentation for persons in care indicated for a person in care their restraint was last reviewed in 2020. The Manager/Administrator stated Occupational Therapist(s) (OT) have been brought in to review the restraint documentation and in speaking with the OT the restraint documentation is 80 - 90% complete.
Corrective Action(s): Please ensure restraint documentation is reassessed/reviewed and documented for all persons in care that this would pertain to.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: A review of the nutrition systems as reviewed with the Food Services Manager and another staff for the contracted company identified staff were not thoroughly documenting substitutions thoroughly. The Food Services Manager and the other staff the writer met with stated the substitution list will be worked on and staff retrained on the use of the substitution list and thoroughly documenting things.
Corrective Action(s): Please ensure thorough records are being kept for the menu substitutions.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A review of the nutrition audits indicated for example the resident satisfaction surveys were last done in 2019. The next scheduled resident satisfaction surveys will be completed in June 2021.
Corrective Action(s): Please ensure nutrition audits are completed according to the Summary of Scheduled Nutrition Audits for the site.
Date to be Corrected: Please provide a written response to this item by the timeline noted in the report.
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