STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Review of employee files found that 1/3 files was missing evidence of compliance with the Province's immunization control program.
Corrective Action(s): Please ensure that all employees have complied with the Province's immunization and tuberculosis control program.
Date to be Corrected: March 19, 2021
CARE AND/OR SUPERVISION: 34840 - RCR s.83(3)(a) - A licensee must review the nutrition plan of a person in care as follows: (a) in the case of a nutrition plan developed under subsection (1), on a regular basis.
Observation: Upon review of person in care (PIC) records determined that 2/2 PIC's had been assessed and mealtime guidelines were provided to guide staff and ensure safe mealtime practices are in place. Of concern is these guideline were dated 2012 and 2015 respectively. It was uncertain if they have been reviewed since they were created and were still appropriate.
Corrective Action(s): Ensure that all nutrition plans are developed and reviewed regularly.
Date to be Corrected: March 19, 2021
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: Review of the menus found that a menu checklist had not been completed. Additionally a nutrition screening form for one PIC was incomplete.
Corrective Action(s): Please ensure that food services and nutrition care are monitored and results are recorded accordingly.
Date to be Corrected: March 19, 2021.
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