Physical Premise: The premise appears to be clean with no noted odors throughout. Furnishings are new and appear to be appropriate to meet the residents needs. Emergency equipment has been serviced with in the last year. Construction of the grounds and access/entry ways continues and there has been a slight delay due to winter weather conditions. The Health and Safety Plans remain in place.
Staffing: Care staff for each level is 1 LPN and 3 RCA's. There is also 2 RCA's who float to provide assistance as needed on the day and afternoon shift. The Clinical lead is available on day and afternoon shift. Management states with the expansion of the facility, there was a high admission rate which resulted in increase demand and work load for staff. However, it is believed admissions have now decreased to a normal rate. CCFL was also advised the staffing level provides the personal care hours as per the provincial standard. There are 15 part time and full time recreation staff. In addition to providing activities and recreation, the recreation staff also assist in the dinning room during meal time(s).
Resident Records: All required documentation is available up to date and includes MOST, Annual Professional Dental visit(s), Admission agreement, consent for release and various risk assessments eg. falls, braden scale and wandering. In regards to the consent for restraint (to a secure unit), it is noted that for residents who were admitted prior to 2016 the forms have not been signed annually. Although admission to a secure unit is normally permanent, consent forms should be signed annually.
Care/Supervision: With the exception(s) as noted in the violation section, items regarding care and supervision appear to be in compliance. Documentation available regarding daily care that is required for each resident is identified in the care plan, (ADL) and for some the Resident Day. In general, care plans appear to be detailed, appropriate and recently reviewed.
Recreation: In review of the activity calendar for the various floors, it appears that activities available are suitable to meet the residents physical, intellectual, emotional and social needs. Activities are available at various times throughout the day and evening and on week ends. At the time of the inspection(s), residents appeared to be engaged in the various scheduled activities. In between the scheduled activities, most residents appeared to be engaged in visiting with each other, with visitors or self engaged. The activity/recreation program includes cooking breakfast with the residents 2 times a week, music therapy, 1:1 visits and/or manicures, various games (for physical/intellectual stimulation), baking, puzzles and a walking program. In review of resident documentation, it includes a list of activity likes and a recreation therapy assessment for each resident.
Nutrition: In review of the documentation for 12 residents, Nutritional assessments have been completed with regular reviews. Nutrition care plans are available and monthly weight is recorded. Food services audits are being completed and records were available for review.
Health/hygiene: On one floor it was noted that nail clippers were not located in the personal compartment(s) provided. The Manager of Care advised nail clippers were purchased for every resident. The rooms of 3 residents were also checked and nail clippers were not located. 2 staff members were questioned as to where they were located but they did not know stating they believed that a recreation staff member does nail care as part of 1:1. As the recreation staff member was not present at the time of the inspection, CCFL was not able to determine if appropriate hygiene is being practiced or not. Therefore, this was not identified as a contravention. However, it is of concern that staff were not aware of who provides nail care or where the nail clippers were located. Please ensure all staff are familiar with who provides nail care and that facility policies are implemented.
Al remaining items as per the above noted guide appear to be in compliance during the process of this inspection.
CCFL would like to thank you for your time and assistance.
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