LICENSING: 30050 - RCR s.8(3)(a) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (a) notify a medical health officer.
Observation: The staff on site at the time of the inspection stated that the licensed manager resigned the position in July 2017. Licensing has not received notification of this change.
Corrective Action(s): Please ensure that licensing receives notification is a manager resigns or is absent for 30 consecutive days.
Date to be Corrected: December 31 2017
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: A review of the main living room found:
- 3 wooden table with chipped and faded wooden tops.
- a leather couch which was fading and caved in when sat on.
Corrective Action(s): Please ensure that all furniture is maintained in a good state of repair.
Date to be Corrected: December 31 2017
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: A review of the physical facility found:
- paintwork in the back living walls is chipped.
- exterior wood panel paint is chipped and pealing in multiple areas.
- a drain pipe cover in the back yard is cracked.
- the frosting on a bedroom window is cracked and pealing.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair
Date to be Corrected: December 31 2017
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: The facility fire drill policy states that staff should complete a monthly fire drill. A review of the fire drills found that none were completed in August and September 2017.
Corrective Action(s): Please ensure that all policies are implemented by employees.
Date to be Corrected: December 31 2017
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: A review of 3 care plans found that all 3 had not been reviewed since July 2016. 2 of the care plans contain information regarding texture modified diets which is now incorrect.
Corrective Action(s): Please ensure that all care plans are reviewed, and if necessary modified, at least once per year.
Date to be Corrected: December 7 2017
NUTRITION AND FOOD SERVICES: 37110 - RCR s.63(2) - A licensee must ensure that food is prepared and served in a manner that, to the extent practicable, is consistent with the personal preferences and cultural background of the persons in care.
Observation: A review of the nutritional care plan binder found that the satisfaction surveys, menu checklist, mealtime checklist, and meals and more checklist were last completed in July 2016. As per the Meals and More binder these documents should be completed annually.
Corrective Action(s): Please ensure that all the audits in the Meals and More checklist are completed at the required intervals.
Date to be Corrected: December 31 2017
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