Hot water temperatures were measured after 1 minute of opening the tap, and measured for 30 seconds or until there was no further increase in temperature. Temperatures ranged from 38.5 degrees Celsius on the west side of the building and 34.5 on the west side of the building. This is well within the limit of 49.0 degrees Celsius required by Residential Care Regulations (RCR)
As Per RCR 37(1)(b), 1 or 2 reference checks were absent from 2 of the 6 staff files reviewed. The present policy requires 2 references. These staff had been employed in the facility for 30(+/-) years, with regular performance reviews conducted by the supervisory staff, and is therefore deemed to meet the intent of the RCR.
The continuing education system was reviewed with the staff responsible for managing Health and Safety and Education. It appears there is a very good system in place. Yearly mandatory education is tracked and there is opportunity for staff to take extra education on line. The results of each staff's education are tracked and forwarded to the HR dept.
The volunteers working in this facility are provided by a contracted agency. It appears that all the RCR requirements for volunteers are documented by the contractor including Criminal Records Checks, references and evidence of compliance with the Provincial immunization and TB Programs as demonstrated by the Activities Coordinator.
It was observed that all employee files (6) contained appropriate documentation for the Provincial Immunization and Tb status.
The Activities Coordinator keeps extensive records for each resident's participation in programs. This allows for matching of programs to individual residents' needs as well as adjusting the programs to match the changing needs of the resident population as a whole.
The facility Policies and Procedures were reviewed. The mandatory policies were observed to be present and the policies were last reviewed in 2017 at Accreditation.
The Nutrition System was reviewed, lunch service observed, and kitchen tour with interview of the cook/Canadian Certified Food Services Manager. Audits were observed. As well this facility has a dietitian 2 days per week. All admissions are provided with nutrition assessment and planning, and all residents' nutrition is reviewed yearly or as changes occur.
The record of monthly weight for one person was documented as refused since Feb 2018. It is the resident's choice to refuse monthly weight. This has been discussed with the family, the physician and the dietitian is actively involved in supporting the resident. This meets the intent of the legislation as part of nutrition monitoring. No further action is requested at this time.
I would like to thank the staff for assistance in completing this inspection.
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