PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: The hot water was allowed to run for 2+minutes in 3 sinks located in the kitchen, the laundry and the upstairs bathroom. The water was measured at over 50 degrees Celsius in each one. The team leader states there is a water mixing valve attached to the hot water tank. Recently, 1-2 days ago, there was work on a hot water line
Corrective Action(s): Please provide a plan that will ensure that the hot water available to residents in the house is regularly monitored in order to ensure that the temperature is maintained below 49 degrees Celsius,
Date to be Corrected: April 9, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: A scatter rug was observed in the laundry. There was no rubberized back and the floor was not slip resistant.
Corrective Action(s): Please ensure that since residents help with laundry, that there is slip resistant flooring in front of the laundry machines.
Date to be Corrected: April 9 2018
STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: The emergency supplies were reviewed. There was no expiry date found on the large water containers, and no label to indicate date of purchase, the smaller, 4 liter containers were outdated the previous July 2017. There were Raman type noodle packages in the emergency food stores, no date could be found on the packages. Emergency training needs to include the importance of observing expiry dates to ensure that in a disaster, the food supplies will be safe for consumption. Review of the fire drills demonstrated no drill for February, but all other previous months were observed to have had a fire drill at least once.
Corrective Action(s): Please provide a plan to describe a system where currency of expiry dates can be ensured for consumables, and fire drills are completed and documented every month.
Date to be Corrected: April 9, 2018
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: Review of the 13 mandatory policies (RCR 85(2)(a-l)) revealed some policies that had not been identified as being reviewed since 2015. These policies are used throughout the PosAbilities" licensed facilities. There was no document that identified that all policies had been reviewed in previous years. This is a repeat contravention and the effect is widespread.
Corrective Action(s): Please provide a plan that will ensure that as per the above regulation, there is yearly review of policy and procedures.
Date to be Corrected: April 9, 2018
CARE AND/OR SUPERVISION: 34090 - RCR s.50(1) - A licensee must regularly monitor the health and safety of each person in care to determine whether the needs of the person in care continue to be met.
Observation: A resident, previously known to writer from another facility, was observed to be pale and appeared to have lost weight. There has been a history of significant health issues for this resident since last seen by the writer, approximately 2 year ago. At this inspection it was observed that monthly weights were often missed for this resident with no reason given. The resident is observed to have significant weight swings, but no audit for "When to call the dietitian" could be found. The resident was reported to have had gastric surgery within the past 2 years and a somewhat lengthy hospitalization. It appears the monitoring of this resident to ensure the resident's well-being is not being completed on a regular basis.
Corrective Action(s): Please provide a plan that will ensure that all residents in this facility are appropriately monitored, not only by the requirements of licensing but the requirements of the individuals' personal status, at all times.
Date to be Corrected: April 9, 2018
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: Response to a previous investigation of a reportable incident where one resident was possibly injured by another resident (broken toe), and the injury had not been identified by staff for an unknown period of time as evidenced by well progressed bruising in the incident report. The 2 residents had a history of a frictious relationship. The facility's investigation response to prevent delayed observation of an injury was to keep a log of observation of the resident's skin. The skin log was requested. It had been completed inconsistently, the frequency had trailed off and the focus of observation had changed from observation for skin injury to observation for excema. Discussion with the manager occurred relating to how changes to an investigation response can occur as the need appears to decline, and the decisions are documented in the care plan. Also strategies for keeping the staff informed of the purpose for the observation log were discussed.
Corrective Action(s): Please provide a plan that will ensure that when a response to an investigation of an RIF is accepted by Licensing, it will be appropriately managed,[ i.e staff training, changes to situation or need, changes to care plan], going into the future.
Date to be Corrected: April 9, 2018
MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored.
Observation: There was no documentation of pharmacy inspection of medication storage area. The manager was unable to locate minutes of a MSAC meeting. The pharmacy cabinet, while maintained inside a locked room, is a tall cabinet with a bored out lock that has not been repaired. Therefore the cabinet does not lock and the storage has not been reviewed by the pharmacist. This is a multiply repeated contravention since 2015..
Corrective Action(s): Please provide a plan of action that will see a functioning MSAC in place with appropriate documentation of pharmacist activities and evaluation of the storage of medications.
Date to be Corrected: April 5, 2018
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: The substitution list was observed for 2017 and 2018. The entries were very few. The substitutions were often not from the same food group or were 'left-overs'. There were no celebration meals or restaurant meals identified.
Corrective Action(s): Please provide a plan that will ensure that staff are educated to the purpose of completion of the substitution list with relation to the monitoring of the residents' nutrition and who will monitor the accuracy of the substitution list.
Date to be Corrected: April 9, 2018
RECORDS AND REPORTING: 39190 - RCR s.78(2)(a) - A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care.
Observation: MARs (Medication Administration Records) were reviewed for February and March. It appears that all signatures were entered with the exception of February 22, 2018 for one resident. The manager was not aware of a leave for that day, it is unusual for a whole day to be missing. There was no code for absence or refusal entered.
Corrective Action(s): Please ensure that all medications are administered according to policy and if not administered by staff, that appropriate notation is entered. Please provide a plan that will ensure that all staff are made aware of the appropriate documentation standards.
Date to be Corrected: April 9, 2018
RECORDS AND REPORTING: 39230 - RCR s.79(1)(a) - A licensee must keep a record in respect of each person in care showing the following information: (a) all money, valuables and other things held by the licensee in trust or safekeeping for persons in care.
Observation: Of 2/4 residents' petty cash checked both were found to have inaccurate totals. One had $9.30 too much, and the other was slightly short. In the historical operational review for this facility, it was noted that there was a history of improper financial management. A discussion was undertaken with the manager about the training of house managers to use Generally Accepted Accounting Principals (GAAP) in managing the funds of vulnerable adults. The manager stated there is an on-line course (RELIAS) provided by the licensee, that the managers are expected to complete.
Corrective Action(s): As this is a repeat contravention. Please provide a plan that will ensure that there is appropriate supervision and training completed to ensure the manager and all staff in the house who are in contact with residents' funds, participate in the training, understand and practice the appropriate money management skills in order to keep the residents' funds in order at all times.
Date to be Corrected: April 9, 2018
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: Observed 2 records, weights were not recorded monthly. This is a repeat contravention from each of the previous 2 years' routine inspections
Corrective Action(s): Please provide a plan that will bring the recording of monthly weights into compliance, is apropriately monitored and is sustainable.
Date to be Corrected: April 9, 2018
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: Audits of the menu were observed but resident satisfaction and when to call the dietitian audits were not observed consistently.
Corrective Action(s): Please ensure that audits are completed regularly.' When to call the dietitian' should be done as a baseline and then again when there are health challenges or changes. The' resident satisfaction audit' should be done yearly. Once the' menu audits' are completed for each of the 4 weeks of the menu both winter and summer, they do not need to be completed again unless there are changes in the menus. Please provide a plan that will educate staff regarding the need for audits as part of nutrition monitoring.
Date to be Corrected: April 9, 2018
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