LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation (CORRECTED DURING INSPECTION): A review of the physical facility found the following:
- 3 salad dressing had expired; 1 in 2014 and 2 in 2016.
- 1 can of soup had expired in 2012.
- 1 box of alcohol swabs in the emergency first aid kit had expired in 2010. Staff have already purchased a new box.
Corrective Action(s): Please ensure that physical environment and the care and services provided by the facility are monitored regularly.
Date to be Corrected: October 31, 2016
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: Licensing noticed throughout the facility that there is painting chipping on the walls and the lower door frames. Discussion with the manager indicated that it has been several years, more then 5, since parts of the facility have been painted.
Corrective Action(s): Please ensure that the facility is maintained in a good state of repair.
Date to be Corrected: November 21, 2016
STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Review of the staff check list determined that 3 out of 9 employees have not had evaluations since 2012 and 2013. Discussion with the manager determined that at least 2 other staff who have been at the facility for at least 3-4 years have never had performance evaluations. Review of the facilities' policies and procedures state that performance evaluations are to happen at least once every year.
Corrective Action(s): Please ensure that the performance of each employee is reviewed regularly.
Date to be Corrected: November 21, 2016
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: Review of the three Persons In Care (PIC) Medication and Administration Records (MAR) found the following:
- 1 MAR had 2 medications that had been administered but not signed for.
- Another MAR had 1 medications that had not been signed for 2 times. Licensing was not able to determine if the medication was given due to it being a spray.
Corrective Action(s): Please ensure that each employee complies with the medication safety and advisory committees policies and procedures.
Date to be Corrected: October 31, 2016
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: 3 out of 3 PIC's files did not have evidence of compliance with the BC immunization program.
Corrective Action(s): Please ensure that each person admitted to the facility comply with the Province's immunization program.
Date to be Corrected: November 21, 2016
NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Review of the menu found that residents receive only two food groups for breakfast during the week. Discussion with the manager determined that 3 food groups are offered, but not recorded on the menu.
Corrective Action(s): Please ensure that residents receive at least 3 food groups for each meal as described in Canada's Food Guide.
Date to be Corrected: November 21, 2016
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: A menu substitution record was observed, but it only went to August 2016. Discussion with the manager determined that substitutions have occurred since then, but that staff have not been recording them.
Corrective Action(s): Please ensure that substitutions are made from the same food group and have a similar nutrition value.
Date to be Corrected: October 31, 2016
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: All 3 residents do not have consent to call a medical/nurse practitioner or ambulance. This is a repeat contravention from last year's routine inspection (NTJN-A33RBF).
Corrective Action(s): Ensure that each PIC has written consent to call a medical/nurse practitioner or ambulance in case of accident or illness.
Date to be Corrected: November 21, 2016
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