PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31240 - RCR s.21(a) - A licensee must ensure that all furniture and equipment for use by persons in care (a) meet the needs of the persons in care.
Observation: At present, there is only one of the 4 female residents who are able to enjoy the use of the bath tub. Two of the PIC's refuse the use of the lift in order to access the tub from above. The remaining resident who walks, is unable to access the tub because the tub will not lower to a low enough position for the PIC to raise a leg to get over the edge. The tub is a fiberglass molded basin that is cantilevered from an upright structure at the faucet end. It is worrisome that if a PIC, in the effort to lean on the side of the tub to raise their leg in order to get in, could displace the tub as it was seen to shift with lateral pressure. As an alternative to soaking in the tub, the residents are rolled over the floor drain in a shower chair and a hand shower is used.
Corrective Action(s): Please provide a plan that will ensure that the residents are enabled to use the tub if they wish
Date to be Corrected: Dec. 15, 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: The many of the kitchen cupboards showed a ring of approximately 3 inches diameter around the cupboard pulls where the paint is worn off.
Corrective Action(s): Please provide a plan that will ensure that maintenance to the cupboards occurs as needed.
Dec. 15, 2017
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31830 - RCR s.36(2) - If necessary to protect the health or safety of persons in care, a licensee must ensure that the outside activity area is secured by a fence or other means.
Observation: This property is situated beside a skytrain station where the train enters an underground section. The length of this section of skytrain property is provided with a solid fence barrier that protects other residential properties from access by skytrain travellers for a distance of approximately 3 blocks. The east facing margin of this property for approximately 60 feet is bounded by a line of conifer trees that have no lower limbs thus providing no barrier to unwanted intrusion. A 'park' is supposed to back onto the property. This leaves the facility property exposed to the hazard of transient persons accessing the building and the vehicles. Evidence of exposure was stated by the manager in that the shed in the garage was entered and refundable recycling was removed and the shed was spray painted with graffiti.
Corrective Action(s): Please provide a plan that will ensure security of the facility property and building.
Date to be Corrected: Dec. 15, 2017
STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Staff performance reviews were observed to be 14-35 months past their due dates as provided by head office to this LO
Corrective Action(s): Please provide a plan that will ensure that performance reviews are brought up to date, as well as a plan that will be sustainable for completion of performance reviews in a timely manner.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34680 - RCR s.81(3)(e)(ii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (ii) a plan for preventing the person in care from falling.
Observation: One care plan was reviewed. The PIC is observably unsteady on standing and transferring. The PIC is aging, had a significant health event in the past year, and there was no fall plan that discussed the limits of the fall risk, nor a fall prevention plan. This is a repeat contravention from last routine inspection.
Corrective Action(s): Please provide a plan that will ensure that all PIC's who may be vulnerable to the risk of a fall are assessed for their level of risk and a fall prevention plan related to that level of risk.
Date to be Corrected: Dec. 15, 2017
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: The immunization and Tb status could not be found for one of the PIC's.
Corrective Action(s): Please provide a plan that will ensure that the immunization status and the Tb status is present and available for inspection for all admissions.
Date to be Corrected: De. 15, 2017
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Appropriate written consent, as above, could not be found for a PIC
Corrective Action(s): Please provide a plan that will ensure that evidence of appropriate consent for all PICs can be retrieved for inspection.
Date to be Corrected: Dec. 15, 2017
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