Accreditation 2026 #7 – Resident Care Experience Pt. 2
Resident Care Experience is one of our Accreditation Themes. It focuses to ensure residents’ needs are met by providing safe and reliable individualized care.
You can download the full version by clicking here: Accreditation 2026 #6: Resident Care Experience Pt. 2
ROP 1 – Suicide Risk Prevention and Safe Environment
Surveyor Question: How does Menno Place ensure a safe and secure environment for residents at risk of self-harm or suicide?
Answer: Menno Place follows established suicide risk policies and safety procedures to maintain a safe environment, including routine safety checks, environmental assessments, and enhanced monitoring when required.
ROP 2 – Suicide Risk Assessment and Referral
Surveyor Question: What happens when a resident screens positive for suicide risk?
Answer: Residents who screen positive for suicide risk are referred to a qualified professional, such as the Social Worker, for assessment. Appropriate interventions, monitoring, referrals, and safety plans are implemented based on the assessed level of risk.
ROP 3 – Individualized Safety Planning
Surveyor Question: How are individualized safety plans developed for residents at risk of suicide or self-harm?
Answer: Individualized safety plans are developed based on the resident’s goals, abilities, preferences, and level of risk. Care plans are regularly reviewed and adjusted as resident needs change.
ROP 4 – Information Sharing During Care Transitions
Surveyor Question: How are residents and families provided with the information they need during care transitions?
Answer: Residents and families receive information and support throughout care transitions, including move-in meetings, orientation resources, the Resident Handbook, and ongoing communication with the care team.
ROP 5 – Information Transfer at Care Transitions
Surveyor Question: How does the team ensure information is transferred accurately and in a timely manner during transitions of care?
Answer: Relevant resident information is communicated effectively during transfers through a combination of verbal reports, electronic health records, and written documentation to support continuity of care.
ROP 6 – Infusion Pump Safety
Surveyor Question: What processes are in place to support infusion pump safety?
Answer: Not applicable to Menno Place.
Accreditation 2026 #6 – Resident Care Experience Pt. 1
Delivering Safe and Reliable Care is a subsection under Resident Care Experience as one of the Accreditation Themes. It focuses to ensure residents’ needs are met by providing safe and reliable individualized care.
You can download the full version by clicking here: Accreditation 2026 #6: Resident Care Experience Pt. 1
ROP 1 Falls Prevention Strategy
Surveyor Question: Tell me about what the Fall Prevention Strategy is for the residents.
Answer: To minimize injury from falls, a documented and coordinated approach for falls prevention is implemented and evaluated.
ROP 2 Skin and Wound Care
Surveyor Question: Tell me what processes are in place for skin and wound care.
Answer: An interdisciplinary and collaborative approach is used to assess residents who need skin and wound care and provide evidence-informed care that promotes healing.
ROP 3 Pressure Ulcer Prevention
Surveyor Question: Tell me what processes are in place to prevent pressure ulcers.
Answer: Risk for developing a pressure ulcer is assessed and interventions to prevent pressure ulcers are implemented.
ROP 4 Suicide Prevention
Surveyor Question: How does your organization identify and document suicide risk among residents?
Answer: Residents are assessed and monitored for risk of suicide.
Stay tuned: Part 2 on Delivering Safe & Reliable Care will be coming out soon.
Thank you for your care and support in making this Accreditation Survey another successful one!
Accreditation 2026 #5 – Medication Management
Medication Management is one of our Accreditation Themes. It covers organizational safety practices related to medication management.
You can download the full version by clicking here: Accreditation 2026 #5: Medication Management
ROP 1 The “Do Not Use” List of Abbreviations
Surveyor Question: At Menno Place, do you ensure that incorrect abbreviations and symbols that may cause errors are not used on any written, printed or electronic materials?
Answer: Yes, we follow the Institute for Safe Medication Practices (ISMP) list of error-prone abbreviations, symbols, and dose designation which is reviewed regularly by our Medical & Medication Safety and Advisory Committee (MMSAC).
ROP 2 High Alert Medications
Surveyor Question: At Menno Place, do you have a comprehensive strategy for managing high-alert medications?
Answer: Yes, we follow the process of our policy RCS 6.13 High-Alert Medications which includes regular education for nurses, audits, and annual policy review.
ROP 3 Heparin Safety and Medication Concentrations
Surveyor Question: How does Menno Place ensure that heparin products are limited and stored safely?
Answer: Heparin is identified as high alert medication. We limit the use of heparin products and order only the low molecular weight heparin under specific circumstances.
ROP 4 Narcotics Safety
Surveyor Question: How does your team ensure that narcotics are stored and used safely?
Answer: Narcotics are identified as high alert medication. We limit narcotics, ensure restricted access, and educate staff on their usage reduces medication errors.
ROP 5 Medication Reconciliations across Care Transitions
Surveyor Question: What process is in place to ensure that the best possible medication history is obtained and that the resident gets the right medication orders?
Answer: Medication reconciliation is conducted in partnership with the resident, family/caregiver and pharmacy to communicate accurate and complete information about medications.
Accreditation 2026 #4 – Infection Prevention & Control
Infection Prevention and Control (IPC) is one of our Accreditation Themes. It covers hand hygiene education & training, compliance with accepted practices, and infection rate tracking and analyzing.
You can download the full version by clicking here: Accreditation 2026 #3: Resident Safety4: Infection Prevention & Control
Surveyor Question: How do we evaluate compliance with accepted hand hygiene practices?
Answer: We evaluate hand hygiene compliance by directly observing (audit) the practice using the Speedy Audit tool conducted by trained peer team member auditors.
ROP 2 Hand Hygiene Education and Training
Surveyor Question: What education and training have you received on hand hygiene?
Answer: We receive regular education assigned to us in Surge Learning, we have visual signs posted throughout our site, we receive hands on education at unit team meetings as required, and get direct feedback by hand hygiene peer auditors.
ROP 3 Infection Rates are Tracked and Analyzed
Surveyor Question: How do we track infection information, analyze it, and communicate this information throughout the organization?
Answer: We track infection rates, analyze the information to identify clusters, outbreaks and trends; this is shared throughout the organization following our policy AP 5.05 IPC Program.
Visit our website for more information on each of these ROP’s
Accreditation 2026 – #3 Resident Safety
Menno Place has a Resident Safety Plan to ensure our delivery of care and services are provided safely to the residents and for the team members. Here is the summary of our Menno Place Resident Safety Plan.
You can download the full version by clicking here: Accreditation 2026 #3: Resident Safety
ROP: Resident Safety Plan
Surveyor Question: Does Menno Place have a developed and implemented Resident Safety Plan?
Answer: Yes, Menno Place has a Resident Safety Plan that identifies, monitors, and addresses resident safety risks to ensure safe, high-quality care.
Evidence:
- Regularly reviews resident care and potential safety risks.
- Monitors quality indicators such as falls, pain, medications, and restraints.
- Uses incident reviews and quality improvement initiatives to enhance safety.
- Investigates resident and family concerns to improve care and services.
ROP: Residents’ Rights and Responsibilities
Surveyor Question: How are residents informed of their rights and responsibilities?
Answer:
Residents and/or their Substitute Decision Maker/Power of Attorney are informed of their rights during admission.
Evidence:
- Rights are reviewed through the Move-In Agreement.
- The Resident Bill of Rights is included in the Resident Handbook.
- The Bill of Rights is posted at Menno Home and Menno Hospital entrances.
ROP: Addressing Resident Rights Concerns
Surveyor Question: What should you do if a resident or family member reports that a resident’s rights have been violated?
Answer:
Listen respectfully, document the concern, and follow Menno Place’s feedback process.
- Menno Place Compliments, Concerns, and Ideas Process available on the family website.
Visit our website for more information on each of these ROP’s
Accreditation 2026 – #2 Safety Culture
ACCREDITATION 2026 – SAFETY CULTURE
Safety is one of our Accreditation Quality Dimensions. It focuses on creating a culture of safety at Menno Place. The following are our ROPs (Required Organizational Practices) that form the foundation of our safety culture.
If you would like a copy of this information for your review you can download it by clicking here: Accreditation 2026 #2 – Safety Culture. You will also find practice questions at the end of this post. All past Accreditation Bulletins are linked here: Accreditation 2026
ROP 1: Resident Identifiers
Surveyor Question: Are at least two resident identifiers used to confirm the resident is receiving the correct care, service, or procedure?
Answer: Resident photos are available on medication carts/outside resident rooms. Second verification is facial recognition through other staff members, families (if they are present), or by resident stating their full name, DOB (if resident is capable).
ROP 2: Workplace Violence Prevention Program
Surveyor Question: Does Menno Place have a documented and coordinated approach to prevent workplace violence?
Answer: Yes, Menno Place has workplace violence and harassment policies, conducts regular risk assessments, and provides mandatory staff training.
ROP 3: Resident Safety Incident Management System
Surveyor Question: Are there processes in place to review resident safety incidents, recommend actions, and monitor improvements?
Answer: Yes, incidents are reviewed through team huddles & meetings, trend analysis, and quality improvement processes guided by established policies.
ROP 4: Safety Incident Management System
Surveyor Question: What is the process to report safety incidents such as near miss, workplace hazards, and employer incident investigation reports?
Answer: Staff can report safety incidents on Quality and Risk Management (QRM) on Surge. All resident related incidents are reported on Point Click Care- Risk Management.
ROP 5: Resident Safety Incident Disclosure
Surveyor Question: Does Menno Place have a documented and coordinated approach for disclosing resident safety incidents to residents and families?
Answer: Yes, resident safety incidents are disclosed and documented according to the Disclosure of Harm or Near Miss policy (AP 2.28) in Surge.
ROP 6: Preventing Falls and Reducing Injuries from Falls
Surveyor Question: How does the team identify residents at risk for falls and implement strategies to prevent falls and reduce injuries?
Answer: Fall risk is assessed on admission and every 3 months, with individualized prevention strategies and care plan reviews for residents with recurrent falls.
ROP 7: Optimizing Skin Integrity
Surveyor Question: How does the team identify residents at risk for impaired skin integrity and implement interventions to prevent skin breakdown?
Answer: Residents are assessed using the Braden Scale, with individualized interventions, treatment plans, and interdisciplinary supports implemented as needed.
Safety Culture: Sample Surveyor Questions
Question: Do you feel Menno Place promotes a just and no-blame culture?
Answer: Yes, staff are encouraged to report concerns and incidents openly to support learning and improvement.
Question: How are resident safety concerns discussed within your neighbourhood or team?
Answer: Safety concerns are discussed during huddles, meetings, and quality improvement reviews.
Question: What can you tell us about the incident reporting process at Menno Place?
Answer: Staff report incidents promptly on QRM on Surge. We can fill out Near Miss, Incident Report, Employer Incident Investigation, and Workplace Hazard Report.
Question: Can you describe an improvement initiative that has been implemented in your area during the past year?
Answer: A few of the initiatives that took place in the past year are new call bell system, new full lifts, and safety huddles.
Question: Why do you think Near Miss Reporting is important?
Answer: Near misses are reported so potential risks can be addressed before harm occurs.
Question: How would you define a harmful event?
Answer: A harmful event is an incident that results in physical, emotional, or psychological harm to a resident.
Question: How does your team learn from incidents and use that information to improve care?
Answer: We review incidents, identify contributing factors, share lessons learned, and implement actions to prevent recurrence.
Visit our website for more information on each of these ROP’s
Accreditation 2026 – The Five Ws
WHY
We want to BEE the best! Being accredited allows Menno Place to be measured against world class evidenced based health care standards. The goal is to provide the best healthcare and services to our residents so we can do what we do best: care for and improve lives.
WHEN
Save the Date: Oct 26th to Oct 29st, 2026.
These are the dates the Accreditation surveyors will be on site. Stay connected by attending your team huddles, reading the https://mennoplacestaff.com/ updates, and participating in the fun events to come.
WHERE
Onsite at Menno Home and Menno Hospital in all areas of care, services, and support.
WHO
Accreditation Canada develops evidence-based standards, assessment programs, and quality improvement solutions. People-centered care philosophy and approach to setting its standards and guiding the accreditation process.
WHAT
The Accreditation Tool is organized into eight chapters:
Chapter 1: Governing LTC Home’s Strategies, Activities, and Outcomes
Chapter 2: Upholding Resident-Centred Care
Chapter 3: Enabling a Meaningful Quality of Life for Residents
Chapter 4: Ensuring High-Quality and Safe Care
Chapter 5: Enabling a Healthy and Competent Workforce
Chapter 6: Enabling Infection and Prevention Control Practices
Chapter 7: Maintaining Safe Medication Management Practices
Chapter 8: Promoting Quality Improvement
