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 40(2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Facility Policy is for staff to have an annual performance evaluation. Out of the 5 staff files that were reviewed, 2 staff required their annual evaluation but did not receive them. Leadership is aware of the outstanding performance evaluation.
Corrective Action(s): Please ensure staff receive their annual performance evaluation as per the Policy and Procedure.
Date to be Corrected: April 15, 2022
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: Of the Policies and Procedures that were reviewed, one of the Policy was last reviewed in September 2019. It appears leadership is in the process of the review of the Policies.
Corrective Action(s): Please ensure Policies and Procedures are reviewed at least once a year.
Date to be Corrected: April 30, 2022
CARE AND/OR SUPERVISION: 34370 - RCR s.63(3)(c)(iv) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iv) reassessed by the person in care's medical practitioner, nurse practitioner or dietitian at least once every 30 days.
Observation: The minimum 30 day reassessment of the ongoing room tray service by the doctor or at least the dietician has not been completed
Corrective Action(s): Please ensure the reassessment has been completed once at least every 30 days.
Date to be Corrected: March 24, 2022
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: 4 out of 6 PIC yearly care plan has not been completed.
Corrective Action(s): Please ensure care plan is each PIC care plan is reviewed at least once a year.
Date to be Corrected: April 13, 2022
NUTRITION AND FOOD SERVICES: 37105 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation: The weekly menu that is posted contained the lunch and dinner menu. Breakfast and snack menu is missing.
Corrective Action(s): Please ensure the weekly menu is complete
Date to be Corrected: March 18, 2022
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(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: 6 PIC were not weighed in the January, reason for the missing information was not recorded.
Corrective Action(s): Please ensure each PIC is weighed at least once a month.
Date to be Corrected: April 1, 2022
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: Review of the snack menu indicates general groupings that are provided for baked items and fruit. The snack menu needs to ensure that variations are available.
Corrective Action(s): Please ensure snack menu provides record to demonstrate that variety of foods are offered.
Date to be Corrected: March 30, 2022
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: The servory refrigerator temperature record was unavailable. Leadership indicated the temperature is monitored and recorded.
Corrective Action(s): Please ensure record is kept to ensure the temperature of the refrigerator is maintained at safe temperature.
Date to be Corrected: March 2, 2022
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