Page 1 Private Nursing Home Annual Inspection Report Facility Name: Garden Home Date of Inspection: November 23, 24, 25,29, Dec 7/ 2022 Address: 310 North River Rd, Charlottetown, PE C1A 3M4 Phone Number: 902-892-4131 Operator: Garden Home Inc. Director of Nursing/Care: Simon Pickles Administrator: Jason Lee Total # of Licensed Beds: 127 Total # of Residents: 124 Level 1: Level 2: Level 3: Level 4: 96 Level 5: 28 Total # of Direct Care Hours Required: 394.4 Direct Care Hours Reported: 448 – 506.75 Care service inspections may be considered technical in nature. Below are some definitions to assist with the understanding of this report. C = Compliance PC- Partial Compliance NC-Noncompliance NA – Not Applicable Criteria for care service inspections are based on legislation and standards that set out requirements to obtain a license to operate a private nursing home. Facilities receive a report of compliance [C] - where all criteria for that standard is met, partial compliance [PC] - where some of the criteria for that standard is met, or non-compliance [NC] - where minimal criteria for that standard is met. PARTIAL COMPLIANCE AREAS IDENTIFIED IN SUBSEQUENT INSPECTIONS MAY RESULT IN NON-COMPLIANCE. Care services inspection reports may also contain recommendations where nursing inspectors identify opportunities for quality improvements that may benefit resident care. LTC – Long Term Care SAST – Seniors Assessment Screening Tool – used to identify Residents needs and helps to inform plan for care NH Reg – Nursing Home Regulation Sec – Refers to Section in the Regulations MAR – Medication Administration Record NH – Nursing Home Standard - Operational and Care Service Standards for Private Nursing Homes is accessible online SMHRT-Seniors Mental Health Outreach Team Page 2 Standard 2.0: Management and Administration Criteria to Follow Legislation and Standards Compliance Level Rating Comments C PC NC NA Mission statement Standard 2.1.1 Goals and objectives of facility support mission statement. Standard 2.1.2 Organizational chart is written, dated and available to all staff. Standard 2.1.3 Residents Rights Policy NH Reg. Sec 23 Standard 2.1.4 Abuse and neglect policies and procedures Standard 2.1.5, 5.3.14 – 5.3.18 General administrative policies and procedures guiding the operation of the facility are approved by management, communicated and accessible to all staff. Standard 2.1.5 Confidentiality policies and procedures Standard 4.5.1, 2.1.5 Contingency plan CCFNH Act Sec 26(2) NH Reg. Sec. 6(4) Standard 2.6.1- 2.6.2 Incident reporting policy and risk management practices NH Reg. Sec 25 & 35 Standard 2.4.3, 2.8, 2.8.8, 2.8.10, 2.8.11, 2.8.12, 2.8.13, 2.8.14, 4.8.10, 4.8.31. ➢ Risk management practices and process requires improvements. ➢ Incidennt follow up(s) requires improvements. ➢ Staff education and in-service training required. Page 3 Significant event policy requirements NH Reg. Sec 35 Standard 2.4.3, 2.7.1 – 2.7.5, 5.3.5, 6.4.3 ➢ Notification of DHW & Board within 24 hours required. ➢ Staff education and in-service training required. Elevator Inspection is current. Reg Sec 4 Standard 2.4: Nursing Service Administration There is a designated Director of Nursing (DON) or Director of Resident Care (DRC) who is a registered nurse (RN). NH Reg. Sec 24-26, 32, 33, 33.1 & 37 Standard 2.4.1- 2.4.3,4.9.1, 4.10.3, 4.10.4, 4.10.5, 7.2.1, 7.4 ➢ Consistently staffing with persons who have demonstrated competencies requires improvements. ➢ Management process for review of incident reports and risk management practices, and implementing and monitoring quality improvements is required. ➢ Management of complaints and concerns requires improvements. ➢ Implementation of Long Term Care Clinical Standards and evidence based practice requires improvements (e.g. Braden skin assessments, falls risk, least restraints, end of life, dementia care, pain and comfort, responsive behaviors, TLR). Designated staff-in-charge assumes responsibility for the operations and care services of the facility for the duration of the absence. NH Reg. Sec 38 (a, b) Standard 2.1.6 Implementation of Evidence-Based Practice Braden Skin Assessment & Interventions NH Reg. Sec 32 Standard 4.4.6, 2.4.3 (Evidence￾Based Practice) LTC Standard ➢ Resident documentation requires improvements. ➢ Supervision and delegation of duties requires improvements. ➢ Resident assessment and updates to care plan requires improvements. ➢ Implementation of policy requires improvements. ➢ Staff education and in-service training required. Falls-risk assessment & interventions NH Reg. Sec 32 LTC Standard Standard 2.4.3 (Evidence-Based Practice) ➢ Resident assessment and updates to care plan requires improvements. ➢ Implementation and updates of policy requires improvements. ➢ Staff education and in-service training required. Page 4 TLR-Transfer-Lift-Repositioning NH Reg. Sec 32 Standard 7.3.1, 4.4.14, 4.4.15, 2.4.3 (Evidence￾Based Practice) LTC Standard Least restraint policy NH Reg. Sec 32 Standard 4.4.26 (Evidence-Based Practice) LTC Standard Safety checks & risk assessments NH Reg. Sec 32 Standard 4.4.24, 4.4.25, 4.4.51 (Evidence-Based Practice) LTC Standard ➢ Improved resident documentation required. Medication reconciliation NH Reg. Sec 22 & 32 Standard 2.4, 4.8.6 ➢ Process improvements required. ➢ Staff education and in-service training required. Standard 2.3: Financial Administration Financial policies & trust accounts NH Reg. Sec 34 & 36 Standard 2.1.5, 2.3 Appendix 8.3 Current & adequate insurance coverage Standard 2.5, 6.3.3 Standard 3.0: Licensing Criteria to Follow Legislation and Standards Compliance Level Rating Comments C PC NC NA License is displayed at main entrance. NH Reg. Sec 3 (3) Standard 2.2.4, 3.1.3 Advertising cites license number and conditions. NH Reg. Sec 3 (4) Standard 2.2.5 Page 5 Policies must be in place to ensure adherence to stipulations under Smoke Free Places Act Standard 3.2.6 Standard 4.0: Resident Care Criteria to Follow Legislation and Standards Compliance Level Rating Comments C PC NC NA Standard 4.1: Admission Process Written admission policies and procedures NH Reg. Sec 24 Standard 4.1.1 Resident admission checklist NH Reg. Sec 24 & 25 (b) Standard 4.1.1- 4.1.10 Resident/family orientation checklist NH Reg. Sec 24 Standard 4.1.6, 4.1.10, 6.1.1, 6.3.1, 6.3.4, 6.5.1 Standard 4.2 & 4.3: Resident Assessment, Plan of Care & Ongoing Monitoring Written policies and procedures in place regarding resident assessment, care review and care plan development. NH Reg. Sec 24 Standard 4.2.1 Level-of-care assessment NH Reg. Sec 24 Standard 2.1.5, 4.2 Resident admission care plan to be completed within 24 hours of admission. NH Reg. Sec 24 Standard 4.2.4, 6.5.2 Comprehensive care plan to be completed within 4 to 6 weeks of admission. NH Reg. Sec 24 Standard 4.2.5, 6.5.3 ➢ Case conference to include RN, family and members of health care team recommended. Review of medical information upon resident’s return from hospital. NH Reg. Sec 24 Standard 4.2.3 Medical records are maintained for each resident. NH Reg. Sec 25 Standard 4.1.4, 4.5.7, 4.8.4 Current medical history and doctor’s orders obtained prior to admission. NH Reg. Sec 25 Standard 4.1.4 Page 6 Time of My Life report Standard 4.1.5, 4.2.3 Goals and plan of care NH Reg. Sec 24 Standard 4.2.7, 4.5.2, 4.5.5 ➢ Documentation of health care and service provided to each resident requires improvements. Regular functional assessments & SAST assessments NH Reg. Sec 24 Standard 4.1.2, 4.3.6, 4.3.10 Resident care plan provides clear direction to staff on approach to meet resident’s needs and personal preferences and they are reassessed for ongoing and changing needs. Care plans and resident documentation reflect evidence of updates and ongoing monitoring. NH Reg. Sec 24 Standard 4.2.6, 4.3.1, 4.3.2, 4.2.10, 4.3.3 4.5.3 ➢ Nurse’s documentation of assessment of resident’s changing needs required. ➢ Staff education and training is required. Monthly documentation and/or periodic updates in progress notes NH Reg. Sec 25 Standard 4.3.8, 4.3.9, 4.5.4 The resident health record is organized similarly for all residents. Standard 4.5.6 ➢ Review of flow sheets recommended. Resident access to outside health resources when conditions warrant them and services are available within the facility. NH Reg. Sec 29, 30, 31 Standard 4.3.5, 4.4.10, 4.4.16, 4.4.50, 4.3.1 Resident discharge and transfer policies and processes Standard 2.1.5, 4.11.2 - 4.11.4 Standard 4.4: Nursing and Personal Care Resident’s family and/or designate and other health professionals to be consulted when planning resident’s care. NH Reg. Sec 24 Standard 4.2.9, 4.2.10, 6.5.5 Page 7 Dementia residents benefit from skilled and competent staff. NH Reg. Sec 23 Standard 7.3 Facility has a policy and procedure in place to provide tube feeding and monitor/ evaluate resident’s response. NH Reg. Sec 30 Standard 4.4.3, 4.7.1 Hygiene and grooming practices are considerate of resident’s preferences (skin care, oral hygiene, and bowel and bladder functional support). NH Reg. Sec 14 Standards 4.4.4 - 4.4.20 ➢ A review and update to bathing schedule is recommended. ➢ Options for evening bathing times recommended. Promotion of resident sleep and rest Standard 4.4.27 – 4.4.30 End-of-life Care NH Reg. Sec 24 Standard 4.2.6, 4.4.37 – 4.4.46, 4.12, 4.12.1, 4.12.2, 4.12.3, 4.12.4, 7.3.1 ➢ Staff education and in-service training required. Standard 4.8: Medication Management Medication Documentation and Reviews The facility maintains a safe and secure resident care based medication management system which promotes resident and staff safety. One that is current and in accordance with legislation, education and professional practice standards. NH Reg. Sec 22 Standard 4.8, 4.8.5 The facility has a contract for specific pharmacy services with a retail pharmacy in accordance with the Private Nursing Home Drug Program. Standard 4.8.1 All medications are prescribed in writing by the attending resident physician or other health professional authorized to do so by provincial legislation. Standard 4.8.2 There is a process in place to ensure the identity of residents prior to administration of medication (i.e. picture with medication administration record). Standard 4.8.3 Page 8 Medications are administered, recorded and monitored by a registered nurse or licensed practical nurse. NH Reg. Sec 22 Standard 4.8.4 Medication management policies NH Reg. Sec 22 Standard 4.8.1- 4.8.6, 4.8.26, 4.8.27 ➢ Updates to medication management policies and procedures required. Medications are reviewed upon admission and at specified intervals by: - A physician, at least biannually; and - A pharmacist, at least biannually. NH Reg. Sec 22 Standard 2.4, 4.3.7, 4.8, 4.8.6 ➢ Frequency of medication reviews by physician requires improvement. Resident’s response to medication is monitored and evaluated by nursing staff, changes are made as required and documented in the resident health record. Standard 4.8.28 A pharmacy prepared medication administration record (MAR) is prepared and issued at least monthly. Standard 4.8.29, 4.8.30, 4.8.31 ➢ Medication errors are to be recorded on an incident report form. The facility has a policy directing the provision of medications to residents on short term leave from the facility including narcotics. Standard 4.8.32 Medication Storage and Handling The facility has policy and process in place regarding recording of narcotics and controlled drug administration and waste. NH Reg. Sec 22 Standard 4.8.7 ➢ Staff education and training recommended. Medications are securely and properly stored. NH Reg. Sec 22 Standard 4.8.9, 4.8.21-4.8.25 ➢ Storage of medications requires improvements. Narcotics are to be counted and co-signed at the end of every shift. NH Reg. Sec 22 Standard 4.8.8 Medication Ordering and Receiving Standing medication orders are to be written by authorized prescriber and resident utilization and monitoring is required. Standard 4.8.2, 4.8.13 – 4.8.15 Page 9 Medical treatments and medication orders are reviewed and signed by a physician (or authorized prescriber) on admission. NH Reg. Sec 22 Standard 4.1.4 New medication orders are accompanied by a new MAR, reviewed by nursing staff at facility upon receipt, and documentation of review is evident. Standard 4.8.16 - 4.8.19 Medication orders are automatically discontinued when a resident is admitted to hospital and new orders written by authorized prescriber and new MARs provided when a resident returns. 4.8.20 Director of Nursing monitors the learning needs of nursing staff and facilitates education and training regarding medication management including administration, review, documentation, handling and storage of new and existing medications. Standard 4.8.33 Director of Nursing reviews medication incident reports, analyzes trends and informs and supports the identification of staff education needs. Standard 4.8.34. 2.8, & 2.8.9 Standard 4.9 & 4.10: Infection Control Infection prevention and control policies and related measures in place to protect residents, staff and visitors of the facility from spread of infectious diseases. NH Reg. Sec 11 & 14 Standard 4.9.2, 4.9.6, 4.9.10 & 4.9.11 ➢ Updates to infection control manual recommended. There are designated areas for staff to wash hands. Standard 4.9.5 Waste and sharps disposal policy Standard 4.9.9 & 4.9.10 All equipment used by more than one resident is cleaned and disinfected between residents. NH Reg. Sec 11 Standard 4.9.7 Personal care supplies used by residents are labeled with the resident’s name, stored in the resident’s room, kept clean and not shared with others. NH Reg. Sec 11 Standard 4.4.17, 4.9.8 Staff health & immunization requirements NH Reg. Sec 21 Standard 4.9.11 4.10.1 ➢ TB Screenings for staff unsatisfactory. Page 10 Prevention of Communicable Diseases Policies Standard 4.10.1 & 4.10.2 ➢ Screening in accordance with DHW Guidelines and facility policy unsatisfactory. Standard 5.0: Physical Environment and Security Criteria to Follow Legislation and Standards Compliance Level Rating Comments C PC NC NA Standard 5.1: Comfortable Environment Bedroom No more than two persons to a room. NH Reg. Sec 12 Standard 5.1.1 Bedroom space and furnishings allocated for each resident meets nursing home regulatory requirements. NH Reg. Sec 12 Standard 5.1.3 ➢ Updates to bedroom space and furnishings recommended Adaptations to the structure and furnishings of the facility meet the safety and security needs of the residents. NH Reg. Sec 13 Standard 5.1.6, 4.4.21, 4.4.22, 4.4.23, 4.4.14, 5.1.2, 5.2.27 Bathroom, Lounge & Dining Area Toilet and bathing facilities meet nursing home regulatory requirements. NH Reg. Sec 14 Standard 5.1.4 The resident has access to common lounge and dining space that meets the nursing home regulatory requirements for space and furnishings. NH Reg. Sec 15 Standard 5.1.5 Wheelchair access to bedroom, bathroom, toilet facilities, dining room and lounge room. NH Reg. Sec 10 Standard 5.1.7 Standard 5.2: Environmental Services An individual is designated for management of environmental services and has responsibilities for implementing policies and procedures, staffing and assignment of environmental services functions. Standards 5.2.1, 5.2.2, 5.2.3, 5.2.4, 5.2.5, 5.2.20, 5.2.23,5.2.32 Laundry service is located away from food preparation or food service areas. NH Reg. Sec 17 Standards 5.2.6, 5.2.7 5.2.12, 5.2.15, 5.2.17, 5.2.18 Page 11 Laundry facilities and procedures are equipped to ensure infection control (i.e. disinfection, etc). NH Reg. Sec 17 Standard 5.2.8- 5.2.14 Water from sources to which residents have direct access must be maintained at a temperature not to exceed 49° Celsius to prevent scaldi NH Reg. Sec 14 Standard 5.2.31 & 5.2.32 Storage of chemicals and dangerous equipment to ensure inaccessibility to residents. Standard 5.2.33 ➢ Secure storage of chemicals and dangerous equipment required. ➢ Staff education and in-service training required. Standard 5.3: Safety and Security A fan-out system to recall staff in the event of an emergency exists and is updated with staffing changes. NH Reg. Sec 19 5.3.11 Written emergency evacuation plan approved by fire inspector and posted. NH Reg. Sec 19 Standard 5.3.6 Monthly fire drills are held, recorded and evaluated. Staff attendance is documented and monitored. NH Reg. Sec 19 Standard 5.3.9, 5.3.10 ➢ Documentation of monthly fire drills not available at time of inspection. ➢ Improvements to monthly fire drill documentation required. ➢ Monthly fire drills are required. A resident and staff list is maintained together with MAR and care plans for emergency evacuations. NH Reg. Sec 19 Standard 5.3.7 & 5.3.8 A current list of emergency telephone numbers is posted and readily available in the event of an emergency. NH Reg. Sec 19 Standard 5.3.4 Missing-resident policy & procedures Standard 5.3.12 & 5.3.13 The facility has basic emergency medical equipment (e.g. oxygen, suction, medications) and supplies as may be recommended by the Board which are kept replenished, in working order and readily accessible to staff at all times. NH Reg. Sec 19 & 20 Standard 4.8.11, 4.8.12, 5.3.22 ➢ Staff education and in-service training required. There is a contingency plan to respond to external disaster or loss of essential services. These plans address response to such events as power failure, failure of heating system, isolation due to weather conditions and emergency staffing plans. Standard 5.3.23 Page 12 Smoking policies for residents and staff Standard 5.2.22, 5.3.24, 5.3.25 The registered nurse, considered “in charge” of nursing services on each shift, is designated to take charge in a medical emergency. NH Reg. Sec 20 Standard 5.3.1 & 5.3.19 The facility has policies to respond to medical emergencies. NH Reg. Sec 20 Standard 5.3.20 All food service and nursing and personal care staff are certified in CPR and anti-choking. NH Reg. Sec 20 Standard 5.3.21, 7.3.1 Standard 6.0: Social Environment Criteria to Follow Legislation and Standards Compliance Level Rating Comments C PC NC NA Social activities are provided inside and outside the facility. NH Reg. Sec 23 Standard 6.1.2 Residents must have opportunity for privacy and independence. NH Reg. Sec 23 Standard 6.1.3, 4.4.54 Opportunity for group and individual activities. NH Reg. Sec 23 Standard 6.1.4 6.5.4 Designated activity staff member or recreation committee NH Reg. Sec 23 Standard 6.1.5 & 6.1.6 Spiritual and religious practices NH Reg. Sec 23 Standard 6.2, 4.4.31-4.4.36 Cognitive orientation and care of residents. Standard 4.4.18, 4.4.19, 4.4.20, 4.4.47, 4.4.48, 4.4.49 Assistance for appointments & transportation to obtain health care services. NH Reg. Sec 31 Standard 6.3.2 Page 13 The facility has a written policy and complaint management process for hearing verbal or written complaints. NH Reg. Sec 23 Standard 6.4.1, 6.4.2, 6.4.3, 6.4.4, 2.4.3 Standard 7.0: Human Resources Management Criteria to Follow Legislation and Standards Compliance Level Rating Comments C PC NC NA Standard 7.1: Orientation Orientation and Skills Evaluation Tool for RNs, LPNs, and RCWs is aligned with job descriptions and scope of practice. NH Reg Sec 32, 33, 33.1 & 37 Standard 4.4.61, 7.1.1, 7.1.6, & 7.1.7 ➢ Written staff orientation checklist for LPNs unavailable at time of inspection. ➢ Written staff orientation checklist for RCWs unavailable at time of inspection. ➢ RCW Skills and Competencies Checklist required ➢ Director of Nursing is responsible for documenting orientation and training of all care staff including RN, LPN and RCW. ➢ Staff members shall not carry a full work assignment until he/she has received the orientation and training. Facility orientation program. NH Reg. Sec 26 Sec 32 & 33.1 Standard 7.1.2 & 7.1.5 Each new staff member is given orientation training appropriate to their role and work responsibilities, as well as orientation training for general facility requirements. NH Reg. Sec 33 Standard 7.1.3 ➢ Orientation training regarding staff role and work responsibilities requires improvements. Standard 7.2: Staffing Registered nurse on duty twenty-four hours per day, seven days a week (24/7). NH Reg. Sec 27 Standard 7.2.2, 5.3.2 The facility has Director of Nursing or Resident care who must be a Registered Nurse. Standard 2.4 & 7.2.1 The facility must have a designated medical consultant. NH Reg. Sec 29 Standard 7.2.3 7.2.4 Page 14 Current job descriptions for all staff. Standard 7.2.12 & 7.2.13 The facility is staffed adequately and appropriately to provide for resident’s safety, comfort and nursing care. There are sufficient RNs, LPNs, and Resident Care Workers to meet the current health needs and degree of activity of residents. Staffing patterns ensure adequate staff coverage for all facility services (e.g. administration, nursing, housekeeping, laundry, dietary service, and maintenance). NH Reg. Sec 37 Standard 4.4.50, 4.4.62, 5.3.3, 7.2.1-7.2.8 Appendix 8.2 There is sufficient staff available in the facility at all times to provide for an evacuation or assistance in a crisis or emergency. NH Reg. Sec 26 Standard 7.2.9 The facility has human resource policies and procedures which are readily accessible to employees. Standard 7.2.8 The facility maintains a personnel record/file for each staff member. NH Reg. Sec 25 & 37 Standard 7.2.9 - 7.2.12, 7.2.14 7.2.16 & 2.4 ➢ Evidence of completion of a RCW Skills and Competencies checklist in personnel files is required. ➢ Evidence of employee immunization records review is required. ➢ Orientation checklist should be contained in personnel records for all employees. ➢ Evidence of employee background checks with at least two most recent employers is required to be documented in personnel files. Occupational Health and Safety Worker’s Compensation Forms Standard 7.2.15, 2.8.13, 2.8.15 Contingency plan for operation that designates who is in charge when the manager is unavailable or away from operations or where there is a disruption due to a labor dispute. NH Reg. Sec 6 (4), 26 (2), Standard 5.3.1 7.2.17 Page 15 Standard 7.3: Staff Development and Training Staff is provided with an opportunity to attend in￾service training courses, both inside and outside the facility. CCFNH Act NH Reg. Sec 32, 33 & 33.1 Standard 2.4 & 7.3.1 ➢ All staff is required to have person-centered care training annually. ➢ Education for all staff on least restraint policy is required in initial orientation with refresher training at least annually. ➢ All staff is required to have evacuation and resident transfer procedure training. The facility has a program which includes identification of staff education needs, delivery or access to the required education/training and records for documenting staff participation and/or certification. CCFNH Act NH Reg. Sec 26, 32 &33 Standard 2.4 & 7.3.2 Records of all education programs are maintained and include the type and length of program and the names of participants. Standard 7.3.2 Standard 7.4: Resident Care Worker (RCW) Personal Care Worker (PCW) Capabilities & Competencies The facility has a program for evaluating the competency of all resident care workers’ ability to perform required duties. NH Reg. Sec 33.1 Standard 7.4.1 ➢ A competency checklist based on the duties outlined in the regulations and job description is required on personnel file. ➢ Documentation is required to indicate the competency level has been met. ➢ Program requires improvements. The facility has a program and processes in place to ensure all care workers have the needed leadership, supervision, coaching, mentoring and evaluation of competencies. NH Reg. Sec 33.1 Standard 7.4.2 ➢ A specific schedule that outlines the learning needs and who is responsible to provide the education and coaching needed to ensure the care worker is competent to perform the required job duties is required. ➢ Annual performance reviews and evaluation are required. Report Received By: CCF & NH Inspector: Signature: Signature: Date: Date: