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: Flooring in the tub room is in disrepair; grout missing and/or damaged between many of the tiles causing them to shift and the floor to be uneven and difficult to keep clean. Tiles along the bottom of the wall below the sink in the tub room have separated from the wall, with some coming off completely and there is a strong mildew smell. The sink is also damaged, with some of the enamel missing, causing the inside to be rusted and difficult to keep clean.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: July 10, 2023
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: Staff confirmed the licensee's policy requires staff to maintain a record all funds and valuables held in trust for persons in care as well as records of the financial disbursements made on behalf of persons in care, ensure receipts are retained and reconcile the PICs accounts each month.
After reviewing the financial records for two PICs, it was confirmed staff did not implement the policy when they did not maintain records in full and/or reconcile the records each month. This is a repeat contravention (see KBEL-CKCPD8)
Corrective Action(s): Please ensure staff implement the policies and procedures of the licensee.
Date to be Corrected: July 10, 2023
CARE AND/OR SUPERVISION: 34360 - RCR s.63(3)(c)(iii) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iii) approved by the person in care's medical practitioner or nurse practitioner.
Observation: One person in care who receives all meals and snacks in their bedroom did not have evidence in their records to confirm the ongoing tray service had been approved by their medical or nurse practitioner as required.
Corrective Action(s): Please ensure approval is provided by the PICs' medical practitioner or nurse practitioner if they are receiving ongoing room tray service.
Date to be Corrected: July 10, 2023
CARE AND/OR SUPERVISION: 34530 - RCR s.74(2)(b) - A licensee must ensure that a person in care is not restrained (b) for the convenience of employees.
Observation: It was confirmed by a review of records and discussion with staff that a restraint is in use for one person in care that is not necessary to protect the PIC or others from serious physical harm. This restraint does not meet the Residential Care Regulation Division 5 - Use of Restraints requirements and is a repeat contravention (see KBEL-CKCPD8).
Corrective Action(s): Please ensure restraint use complies with the Residential Care Regulation and is not for the convenience of employees.
Date to be Corrected: Immediately
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: The care plans for two persons in care were reviewed.
- One PIC had experienced substantial changes in the care they required, however their care plan had not been modified to include sufficient information to guide staff related those changes.
Corrective Action(s): Please ensure care plans are modified when substantial changes occur.
Date to be Corrected: July 10, 2023
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: The Care Plans for two persons in care (PIC) were reviewed and both require staff to complete specific monitoring and document the results. The documentation records for both persons in care were incomplete and it could not be confirmed staff were monitoring the two persons in care as required by their care plans.
Corrective Action(s): Please ensure the care plan of persons in care are implemented by staff as required.
Date to be Corrected: July 10, 2023
NUTRITION AND FOOD SERVICES: 37050 - RCR s.62(2)(c)(i) - A licensee must ensure that each menu provides (c) a variety of foods, taking into consideration (i) the nutrition plan of each person in care and the nutrition needs, age, gender and level of activity of the persons in care.
Observation: There was no evidence to confirm the four week menu in use at the time of inspection took into consideration the individual nutrition care plans developed by the Registered Dietician for two persons in care.
Corrective Action(s): Please ensure menus developed consider the nutrition plan of each person in care.
Date to be Corrected: July 10, 2023
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: One person in care is not weighed each month as required. This is a repeat contravention (see KBEL-CKSPD8)
Corrective Action(s): Please ensure each person in care is weighed as required.
Date to be Corrected: July 10, 2023
RECORDS AND REPORTING: 39600 - RCR s.91(2)(a) - In respect of a record referred to in this regulation, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 78 to 81, 85, 88 and 89.
Observation: It was confirmed at the time of inspection records of incidents, both reportable to CCFL and not reportable to CCFL were not retained at the facility and that copies of all the licensee's policies and procedures, including those developed by the Medical Safety and Advisory Committee had been removed from the facility to be updated.
Corrective Action(s): Please ensure records are retained at the facility as required.
Date to be Corrected: July 10, 2023
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