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:
- wall patches where the painting needed to be completed in several areas
- the blue rim around the tub in the tub room is coming off. The DOC stated this requires regular repair and the lift rubs it off
- there are two spots on the outside common area where the concrete walkway is lifted and causes a tripping hazard. The DOC noted this is repaired regularly as it is caused by the growth of large trees on the property
- 2 bedrooms had baseboards that were lifting
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair
Date to be Corrected: October 31, 2018
POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation: Inspection of the emergency supplies for the site found that the site does not currently stock food in dry storage for emergency purposes. There are some foods kept in the fridge/freezer storage that is used and restocked regularly. The site has food delivery from Queen's Park several times a day for regular food service. In the event of an emergency where Queen's Park could not deliver food, Burnaby Hospital is the back up. If food delivery was not possible in the event of an emergency current stores would be inadequate for PIC's and staff.
Corrective Action(s): Ensure that the emergency plan includes food available on site for PIC's in the event that food cannot be delivered.
Date to be Corrected: August 31, 2018
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: On inspection the LO noted on the Parkside dining room fridge and the small nourishment kitchenette room that the temperatures for fridges was missing several dates (20+ in May 2018) there were 4 instances where temperature was recorded that was out of the safe range (above 4 degrees). No action was indicated that there was follow up to ensure appropriate fridge temperature. The RD stated she will look into revising the form to add a column to indicate what action was taken when the fridge is out of range.
Corrective Action(s): Ensure that a system is in place to ensure safe storage of food at safe temperatures with follow up to ensure this is consistently occurring.
Date to be Corrected: July 31, 2018
RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: Review of 4 intake records found that 2/4 did not include admission weights. Staff confirmed that weight is occasionally taken from intake documents received, and not taken at the site until the next regular month's weigh time.
Corrective Action(s): Ensure that an intake weight is taken on site for each PIC on admission.
Date to be Corrected: July 31, 2018
RECORDS AND REPORTING: 39330 - RCR s.83(4)(c) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (c) record the weight in the nutrition plan of the person in care.
Observation: Review of the weight records for all PIC's found 1 weight missing in January 2018, 5 missing in March 2018 and 1 missing in May 2018 without any notes as to why it was incomplete.
Corrective Action(s): Ensure that weights are taken and recorded monthly. If a weight cannot be completed document the reason
Date to be Corrected: July 31, 2018
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