PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: During the inspection the LO noted that the laminate counter in B wing on the 2nd floor was chipped down to wood making effective sanitization difficult.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: March 31, 2019
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31790 - RCR s.35(2)(b) - A licensee must ensure that laundry facilities (b) if not used by persons in care, cannot be accessed by persons in care.
Observation: On inspection there was an unlocked utility room in B wing that had dirty items accessible to PIC's
Corrective Action(s): Ensure that all dirty linen areas and rooms with hazardous materials are inaccessible to PIC's
Date to be Corrected: March 1, 2019
STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Review of staff files and discussion with the GM found that the support services department had a change in manager. This has caused a delay in the performance evaluations for this department. A new manager has been orientated and a plan to complete performance evaluations this year has been created.
Corrective Action(s): Ensure all employees have performance evaluations within the time frame of facility policy
Date to be Corrected: May 31, 2019
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: Review of 5 care plans found that 1 PIC had an updated MOST in the green sleeve of "M2" but the care plan and front page of the PIC's binder stated "M3"
Corrective Action(s): Ensure that the care plan is updated when there is a change in circumstances for PIC's
Date to be Corrected: March 1st, 2019
NUTRITION AND FOOD SERVICES: 37080 - RCR s.62(2)(c)(iv) - A licensee must ensure that each menu provides (c) a variety of foods, taking into consideration (iv) the texture, colour and matters that affect food safety, taste and visual appeal.
Observation: Discussion with staff and two PIC's found that there were some concerns about the temperature of the food served, and how that affects the appeal to eat the food.
Corrective Action(s): Ensure that consideration is taken so that the food has temperature, taste and appeal for PIC's
Date to be Corrected: April 30, 2019
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