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: It was observed that the kitchen cabinets were in disrepair, with the melamine surface cracked and peeling in numerous areas, and with one missing door. The kitchen countertop was worn in several areas, one areas worn down to the bare wood. Of concern is the inability to sanitize the countertops. The wall behind the stove was bare drywall with holes in it. There were also several areas throughout the home where the walls were scuffed and in need of paint and repair.
In discussion with the facility manager, it was determined that the kitchen is expected to be renovated, however a scheduled date for the work to begin could not be provided.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: February 24, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: Upon inspection of the medication room, it was observed that the locks on the cupboards were not functioning and in use were plastic safety clips which do not provide secure storage. In discussion with the facility manager it was determined that this needed repair was brought to the attention of BC Housing, however no date has yet been set to make the repair.
Corrective Action(s): Please ensure that all medication are safely and securely stored.
Date to be Corrected: February 24, 2021
STAFFING: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: The facility manager disclosed that the employee performance evaluations have not been conducted as scheduled. This is a repeat contravention from the last routine inspection conducted in 2018.
Corrective Action(s): Ensure that the performance of each employee is reviewed regularly.
Date to be Corrected: February 24, 2021.
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: Upon review of the PIC's care plans, it was found that there were safety concerns related to one PIC where he was not to have access to car keys. It was observed that a set of car keys were left out where the PIC could potentially access them, contrary to his care plan.
Corrective Action(s): Ensure that the care and supervision is consistent with the terms and conditions of the PIC's care plan.
Date to be Corrected: February 24, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Upon inspection of the freezer it was observed that there were several items that were not labelled, dated and sometimes not properly sealed. It was also noted that although the staff regularly monitor the fridge temperature, it was observed that the reading has consistently been high at 6 degrees or higher (above the safe food storage temperature of 4 degrees or less). Of concern is that although staff were recording the temperature, they were unaware of what the safe zone is, or what action should be taken if the temperature is out of the safe zone.
Corrective Action(s): Please ensure that all food is safely stored.
Date to be Corrected: February 24, 2021
RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: Upon review of 4 care plans, it was determined that the admission height of 2 PICs and the admission weight of 1 PIC were missing.
Corrective Action(s): Ensure that the height and weight of each PIC is recorded.
Date to be Corrected: February 24, 2021
RESIDENT BILL OF RIGHTS: 40060 - CCALA s.7(1)(b)(ii) Schedule 1-2(d) - To have his or her personal privacy respected, including in relation to his or her records, bedroom, belongings and storage spaces.
Observation: It was observed that 2 persons in care (PICs) were being monitored with the use of a baby-monitor-style device. In discussion with the staff it was determined that the 2 PICs are monitored throughout the night with the use of this device, reportedly due to safety concerns. The use of such a monitoring device was not found in either PIC's care plan. Use of such a device raised the following concerns:
1. How has it been determined that the use of these devices are appropriate to mitigate risk for the PICs and their nighttime behaviours?
2. Who has made these determinations and has the Residents Bill of Rights been considered?
3. Has approval from appropriate stakeholders for the use of the devices been received?
4. Have guidelines for the use of the devices been provided to the staff on appropriate use of the devices? Of concern is the devices were on during the day and the monitors were placed on the kitchen counter in view of all persons in the home including staff, visitors and other PICs.
Corrective Action(s): The Residents Bill of Rights must be considered when developing a safety plan for persons in care.
Date to be Corrected: February 24, 2021
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