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: One chair in an area utilized by a person in care is worn and the leather or leather type seat surface has cracks.
Corrective Action(s): Ensure all furniture and equipment are maintained in a good state of repair.
Date to be Corrected: April 13, 2018
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: In one person in care’s bedroom, there is no closet door. In addition, there is no information as to the reason for the lack of a closet door.
The Floor in front of on bathroom that leads into laundry area is not finished and cement is exposed.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: April 13, 2018
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: Two person in care closets had items stored on floor preventing potential for cleaning and items to be less clean stored on the floor.
Corrective Action(s): Ensure all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: April 13, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31550 - RCR s.29(1)(a) - A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including (a) a safe, secure place in which the person in care may store valuable property.
Observation: One person in care purchased his own hospital bed – which is required for his care
Corrective Action(s): Ensure person in care needs are provided with furnishings to meet their needs at no additional cost.
Date to be Corrected: April 13, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31610 - RCR s.30(d) - A licensee must ensure that all bathrooms have (d) any other equipment that is necessary to protect the health, safety and dignity of the persons in care.
Observation: Both bathroom, no papertowel, one bathroom- toilet paper is stored in cupboard which is out of reach from the toilet.
Corrective Action(s): Ensure that all bathrooms have equipment that is necessary to protect the health, safety and dignity of the persons in care.
Date to be Corrected: April 13, 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: Although the Laundry is not used by persons in care, it is accessible by persons in care as it is in one person’s living space. There is no slip resistant flooring in the laundry area.
Corrective Action(s): Ensure that laundry area accessible to persons in care have a slip resistant flooring.
Date to be Corrected: April 13, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31820 - RCR s.36(1)(c) - A licensee must provide outside activity areas that have (c) comfortable seating including a reasonable amount of shelter from sun and inclement weather.
Observation: Review of the outdoor space, there is no covering overhead to protect persons in care from inclement weather.
Corrective Action(s): Ensure outside activity areas include a reasonable amount of shelter from sun and inclement weather.
Date to be Corrected: April 13, 2018
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: The last Medication Safety and Advisory meeting occurred in March 2017. It is noted in the meeting minutes that the next meeting was to occur in 6 months. This meeting has not occurred and no documentation was noted to state the reason the meeting had not occurred.
For the 2 person’s records that were audited, PRN protocols were from June 2015 for one person in care and 2016 for the other. There was no documentation to confirm a review occurred.
In an audit of 2 person care records, 3 prn results were not documented.
Corrective Action(s): Ensure policies of the medication safety and advisory committee are followed.
Date to be Corrected: April 13, 2018
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: For person in care residing on the lower floor – no restraint consent in place for door to upstairs that is locked if staff need to leave the person in care and go upstairs. In addition there is no consent is place for use of the lap belt for the person in care when utilizing the person’s wheelchair.
Corrective Action(s): Ensure there is an agreement to the use of a restraint given in writing by both the person in care’s family/representatives and medical/nurse practitioner. This contravention includes code 33180 RCR s. 74(1)(b)(ii)
Date to be Corrected: April 13, 2018
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: please see code 33170 RCR s. 74(1)(b)(i).
Corrective Action(s):
Date to be Corrected:
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: In an audit of 2 persons care records, on the form that is named Dietary Supplements and Skin Care Regiments – for both persons in care, from 17 to 33 signatures were missing for completion of work for both January and February. For one of these persons, there was no February form located. Discussion with the manager on day 3 confirmed that either a signature or a reason is to be documented for each care item if not signed off.
Corrective Action(s): Ensure staff are following protocols in place.
Date to be Corrected: April 13, 2018
CARE AND/OR SUPERVISION: 34610 - RCR s.81(3)(a)(ii) - A care plan must include all of the following: (a) a plan to address (ii) behavioural intervention, if applicable.
Observation: One person in care requires video monitoring as part of his behaviour plan when staff leave the person in care to go upstairs for meal preparation or assistance to other staff. There is no Information in the care plan regarding requirement of video monitoring. Although the family are aware, there is no consents in place for approval of the use.
Corrective Action(s): Ensure care plans include a behaviour intervention plan
Date to be Corrected: April 13, 2018
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: The food and nutrition assessments for two persons in care audited could not be located by licensing on day one of the inspection or the manager on day 3 of the inspection. Available copies were from May 2016. Although the manager states that the assessments were completed, there was not any evidence to confirm the assessments were completed.
Corrective Action(s): Ensure documentation for nutrition plans audits to assess the person in care’s nutrition status are current.
Date to be Corrected: April 13, 2018
CARE AND/OR SUPERVISION: 34650 - RCR s.81(3)(c)(ii) - A care plan must include all of the following: (c) a nutrition plan that (ii) specifies the nutrition to be provided to the person in care, including the requirements of any therapeutic diets.
Observation: There were not any meal time guidelines in place to guide staff on persons in care needs for meals on day 1. It was confirmed by the manager on day 3 that only 1 of 4 was completed after day one of the inspection.
Corrective Action(s): Ensure plans to specify the nutrition to be provided to the persons in care is available.
Date to be Corrected: April 13, 2018
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: TB screening could not be located for the two persons in care’s records that were audited by licensing. The guideline in place for TB programs in the care plans were copies meant for staffing requirements.
Corrective Action(s): Ensure evidence of compliance with Province’s Tuberculosis control programs.
Date to be Corrected: April 13, 2018
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: Menu audits for only one week of the spring/summer menu was completed. Discussion with the manager was that staff were to complete the other weeks. This had not occurred to date.
Review of the spring/ summer menus, on day 1of the inspection, lunches were written as leftovers. Staff stated that it would be the meal from the day before. Review of nutrition binders, each week only had approximately 3 recipes to guide staff on meals. Discussion with the manager on day 3 of the inspection and review of the menu – changes were made to state that leftovers were sandwiches. Of concern, there is no direction for staff to ensure that they are providing food to meet the nutritional needs for the persons in care. In addition, when the leftovers and now various sandwiches are served, there is no indication as to what was served as they do not document this. With the meals, the manager stated that staff are encouraged to use the internet to find a variety of recipes for use. The manager could not confirm which recipes were used for the menu audits, in addition, the lack of recipes or portions of ingredients for each day, cannot confirm that meals provided are sufficient in nutritional value for the persons in care on a daily basis.
Corrective Action(s): Ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada Food Guide and the person in care’s nutrition plan
Ensure audits are completed to confirm meeting the requirements of the Canada Food Guide are completed for each week.
Date to be Corrected: April 13, 2018
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 financials for 2 persons in care, it was observed that one person in care on a minced diet was charged for a hand chopper that is required on outings.
Corrective Action(s): Ensure licensee provides each person with eating aids as required for care.
Date to be Corrected: April 13, 2018
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