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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-CBPPVC

FACILITY NAME
Menno Place - Menno Home
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
0775014
FACILITY ADDRESS
32910 Brundige Ave
FACILITY PHONE
(604) 853-2411
CITY
Abbotsford
POSTAL CODE
V2S 1N2
MANAGER
Kim Scott

INSPECTION DATE
February 15, 2022
ADDITIONAL INSP. DATE (multi-day)
February 17, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
9
ARRIVAL
12:30 PM
DEPARTURE
04:30 PM
ARRIVAL
08:30 AM
DEPARTURE
01:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records, and information provided by the facility staff at the time of inspection.

Care systems reviewed during inspections include: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & Reporting.

As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation.

Visit the CCFL website at www.fraserhealth.ca/residentialcare for additional resources and links to the legislation (CCALA & RCR).

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Water temperatures were sampled throughout the building and temperatures ranged from 50-52 degrees. Discussion with maintenance determined that the facility has been actively working to keep water temperatures below 49 degrees, and there is a system in place to monitor water temperatures.
Corrective Action(s): Ensure that water assessable to persons in care, is not heated to more than 49 degrees Celsius.
Date to be Corrected:

CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: 2 persons in care who have consented to receive dental hygiene services through the facility, did not have evidence of being encouraged/ or having a dental health exam since 2019. Discussion with the DOC determined that there has been challenges with receiving dental services due to the pandemic/ outbreaks.
Corrective Action(s): Ensure persons in care are encouraged to be examined by a dental health care professional at least once every year.
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: 2 persons in care out of 5 reviewed did not have monthly weights documented for 3/12 months reviewed, and 1/12 months reviewed. There was not reasons recorded, as to why the person in care was not weighed.
Corrective Action(s): Ensure that if a person in care refuses, or is unable to be weighed, the reason why the person was not weighed is documented.
Date to be 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: Upon inspection of Kitchenette fridges, it was found that in at least 3 kitchenette fridges there was food that had been removed from its original packaging, that was not labeled (including what appeared to be leftovers). In the Main kitchen there was an open package of dry goods, that was removed from its original packaging and not labeled.
Corrective Action(s): Ensure that all food is safely prepared, stored, served and handled.
Date to be Corrected: February 25, 2022


Comments

Copies of the inspection report and the Facility Risk Assessment Tool were reviewed, discussed, and provided to the Licensee/Manager.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.