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: The water temperature taken was 52.6 degrees in the main floor bathroom.
Corrective Action(s): Ensure that the water accessible to PIC's does not exceed 49 degrees
Date to be Corrected: June 15, 2018
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: On inspection the LO noted:
- white build up on the shower curtain and brown staining on the bath/shower mats in the main floor bathroom/shower
- paint worn off on the bathroom door and the baseboard beside the toilet area
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: September 15, 2018
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: Out of 4 care plans reviewed, 1/4 included a nutrition assessment that was dated December 2016. A nutrition care plan was completed in Feb. 2018
Corrective Action(s): Ensure that all areas of the care plan are completed every 12 months.
Date to be Corrected: July 15, 2018
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: Review of records and discussion with staff found that historical immunization records are not currently kept by the site. (TB and annual vaccinations are)
Corrective Action(s): Ensure that all PIC's have evidence of compliance with BC's immunization program
Date to be Corrected: November 15, 2018
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: Review of 2 weeks of the spring summer menu found several instances where only one food group was listed for snack. The manager confirms that a second food group has been added, but it is not yet reflected on the menu. This is a repeat contravention from the 2016 and 2017 inspections.
Corrective Action(s): Ensure that the menu reflects the food provided and includes 2 food groups for both snacks.
Date to be Corrected: June 30, 2018
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Review of the menu audits found 2 weeks of the spring and summer menu, which included 4 instances where the menu did not meet the Canada Food Guide requirements, and no change was completed to the menu.
Corrective Action(s): Ensure that there are menu audits completed for each week of the spring summer and fall winter menus and updates are completed as required when the menu does not meet the Canada Food Guide requirements.
Date to be Corrected: August 31, 2018
|