LICENSING: 30020 - RCR s.8(2)(a)(i) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (i) plans for the change.
Observation: structural change to the outdoor space and yard is in progress, without notice being provided or approval of a health and safety plan. The fence has been removed and temporary fence has been put in place by the construction company.
Corrective Action(s): Ensure for any structural changes to the premise, a plan for the change is submitted to licensing. Please including plans for the change, as well as a description of how the Licensee intends to ensure the health and safety of persons in care while the change is being made. As well as a health and safety plan for persons in care to access to the outdoor space during construction.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: Some equipment and furnishings are not in a good state of repair, including: a wipe able futon that has multiple cuts and holes, making it difficult to clean; a bench near the front door has a wood piece broken off and missing; dinning chair has a large hole in both fabric and foam padding, making it esthetically unpleasing and difficult to clean; the couch shows wear and is torn, making it difficult to clean; bath towels are frayed and threadbare (corrected).
Outdoors: paint is chipped off wood patio furniture, making it a potential risk for splinters or injury; a mat used for sitting on the ground is covered in cobwebs and visible dirt, and being inappropriately stored outdoors where it is exposed to the elements (corrected); 2 of 3 pot lights on the patio are missing the casing around them leaving a large gap (corrected).
Corrective Action(s): Please provide a plan of corrective action to ensure that equipment and furnishings are in a good state of repair.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: Some equipment and furnishings are not in safe and clean condition, include: A white step stool in bathroom that was visibly soiled with dark patches of dirt; A mattress was inappropriately stored in the garage, standing up on its side on the bare floor, uncovered and behind recycling and garbage bins, making it unsanitary for use by persons in care (corrected); The craft closet had storage containers and other items stored on the floor, making it difficult to clean (corrected), with visible dust and debris around items; A gas can stored inappropriately outside and beside BBQ, is a safety risk (corrected); A toilet brush visibly soiled and stored inappropriately with other equipment and supplies under sink, including attends and urine collection hats (corrected); 2 ostomy measuring cups for 1 person in care stored on widow sill, and under sink storage with other items.
Corrective Action(s): Please provide a plan to ensure that equipment and furnishings are in safe and clean condition that is compatible with the health, safety, and dignity of persons in care. Ensure that like items are stored together, and separately for each person in care, as well as personal items stored apart from cleaning supplies.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Some rooms and common area were not in a safe and clean condition, as follows:
In the kitchen, the bottom drawer on the stove/oven is broken and hanging. There was visible spills/ soiling on kitchen floor.
Bathrooms: All 3 bathrooms (including staff bathroom) have a large amount rust on the door behind the toilet; the bathtub has rust around the drain, and tub is discolored and has broken/ cracked tile around it, making it a potential risk for injury; the grab bars in both person in care bathrooms have excessive rust;
Note: manager states that BC housing is aware of the issues in the Bathroom and plans to repair the bathroom (with the tub) this year.
Laundry room: the dryer door (bottom) is broken and taped together; the cupboard doors don’t open, close or lock as cupboards are in poor condition; floor is discolored and esthetically deteriorating. Manager states that BC housing has told her that the plan is for the dryer to be replaced.
Corrective Action(s): Please provide a plan to ensure rooms and common areas are maintained in a safe and clean condition that is compatible with the health, safety and dignity of persons in care.
Date to be Corrected:
POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation: The emergency food supply, was not kept separated from the regular food supply.
Corrective Action(s): Please ensure that a plan sets out how persons in care will continued to be cared for in the event of an emergency, including emergency food supply and menu.
Note: It was discussed with the manager of Culture and Mentorship with the H.O.M.E society that each home must have a separate emergency food supply and menu.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34900 - RCR s.83(5)(a) - If a person in care refuses or is unable to be weighed, the licensee must (a) record in the nutrition plan of the person in care the reason why the person in care was not weighed.
Observation: Weights not documented for 2 of 2 Persons in care reviewed, for 2-4 month gaps a reason for refusal is not documented
Corrective Action(s): : Ensure that if a person in care has not be weighed, the reason shall be documented.
Date to be Corrected: Corrected
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Stale bread was found inappropriately stored in the garage, in a bin without a lid (corrected). Other food was inappropriately stored near paint and cleaning supplies in the garage food storage area (corrected). Chest freezer had more than an inch of ice build up and has not been defrosted for quite some time.
Corrective Action(s): Ensure food is safely prepared, served and handled, and any food waste is appropriately removed. Store food away from cleaning supplies, paint, and other supplies.
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: It was noted that on many days of the week snacks were served, containing only one food group (Ie) Fruit and Tea.
Note: The manager of culture and mentorship advised that the H.O.M.E society has registered 15 staff for an upcoming nutrition training session with the Licensing dietician.
Corrective Action(s): Ensure that each day at least 2 nutritious snacks are served, with each snack containing at least 2 food groups as described in Canada’s food guide.
Date to be Corrected:
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