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: During inspection the LO observed:
- a hole in the wall in the hallway
- the outside awning cover has a section that is sagging and coming down
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: September 30, 2016
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: There were stains and dirt visible on the carpet in the bedroom of one of the PIC's
Corrective Action(s): Ensure all areas are maintained in a safe and clean condition
Date to be Corrected: September 30, 2016
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: A review of the staff checklist found that several staff had no dates listed for peformance evaluations. Staff reported that the current manager just returned from leave and the manager that was covering for one year did not complete employee evaluations so none were done in this time period
Corrective Action(s): Ensure performance evaluations are completed as required
Date to be Corrected: October 31, 2016
CARE AND/OR SUPERVISION: 34640 - RCR s.81(3)(c)(i) - A care plan must include all of the following: (c) a nutrition plan that (i) assesses a person in care's nutrition status.
Observation: In 2/3 care plans reviewed the nutritional assessment was not completed
Corrective Action(s): Ensure the nutrition plan of all PIC's includes a nutritional assessment
Date to be Corrected: September 15, 2016
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: 1/3 care plans reviewed had several documents that had last been reviewed in May 2015
Corrective Action(s): Ensure all care plans are reviewed at least once each year
Date to be Corrected: September 15, 2016
CARE AND/OR SUPERVISION: 34900 - RCR s.83(5)(a) - If a person in care refuses or is unable to be weighed, the licensee must (a) record in the nutrition plan of the person in care the reason why the person in care was not weighed.
Observation: 2/2 care plans reviewed had blank spaces for wieghts for 2/14 months
Corrective Action(s): Ensure if PIC refuses or is unable to be weighed, there is a reason documented
Date to be Corrected: August 31, 2016
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: 2/3 of the care plans reviewed did not include evidence of PIC compliance with immunization or TB control programs.
Corrective Action(s): Ensure all PIC files include documentation to show compliance with the province's immunization and TB control programs
Date to be Corrected: September 30, 2016
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: Review of the menu found and discussion with staff found that:
- left over's from dinner the night before is almost always served for lunches
- the same items are listed for breakfast and the two snack times each day for the 3 weeks reviewed
Corrective Action(s): Ensure that the menu and food served provides variety
Date to be Corrected: September 30, 2016
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: A review of the menu found that PIC's are offered a list of options every day for breakfast and the two snacks. Lunch states leftovers or soup and sandwich (without naming the type of soup or sandwich) each day for the three weeks of menus reviewed. The facility is not able to adequately audit the foods served to ensure each PIC is receiving foods to meet their personal nutritional needs as there is not documentation to show what each PIC is eating on a daily basis.
Corrective Action(s): Ensure that documentation and menus reflect the foods provided each day to all PIC's
Date to be Corrected: September 30, 2016
NUTRITION AND FOOD SERVICES: 37210 - RCR s.67(1)(a) - A licensee must provide each person in care with (a) nutrition supplements required by the person in care's nutrition plan or ordered by the person in care's medical practitioner or nurse practitioner.
Observation: Review of PIC finances found that 1 PIC had a receipt for supplements in 3 flavours that he purchased. Staff confirmed he does need and receive supplements.
Corrective Action(s): Ensure that the facility is providing these supplements as required
Date to be Corrected: August 30, 2016
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