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: Upon inspection of rooms and common areas, the following was observed:
- Approximately 50% of the freezer door in the lower suite has rust covering the surface.
- The downstairs pantry/closet has an exposed electrical outlet box on the wall.
- The upstairs main bathroom has 5 cracked floor tiles, melamine peeling off the side of a cabinet door, and rust covering approximately 50% of the bathtub grab bars.
- The upstairs ensuite bathroom floor has a tear of approximately 4 in. by 2 in. in the linoleum, exposing the subfloor. There is discoloured linoleum approximately 6 to 8 inches around the perimeter of the toilet base.
- REPEAT CONTRAVENTION: The kitchen oven’s bottom compartment door is broken, the kitchen cabinet drawers have paint peeling off, and the countertops have 3 circular patches approximately 12 inches in diameter where the surface has worn away. Management informed the LO that the range and new kitchen cabinets and cupboards were not replaced by BC Housing as scheduled in January 2020 and the facility has not been provided with a new date for the repairs. Ensure an anticipated date for the kitchen repairs are provided by the correction date below.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: April 23, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation (CORRECTED DURING INSPECTION): A cleaning agent was stored in an unlocked cupboard in an area accessible by persons in care.
Corrective Action(s): Corrected at time of inspection.
Date to be Corrected: Corrected at time of inspection.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation (CORRECTED DURING INSPECTION): One topical medication was stored with oral medication. A second topical medication was missing a portion of the pharmacy label which displayed the PIC name. The mixing of medications between storage locations and the requirement to ensure labelling of topical medications were items identified by the pharmacist during the previous pharmacy inspection, which occurred October 14, 2020.
Corrective Action(s): Corrected at time of inspection.
Date to be Corrected: Corrected at time of inspection.
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation (CORRECTED DURING INSPECTION): Medication Administration Records (MAR) had not been updated for the current month in PIC medication binders and did not include a medication presently in use by a PIC.
Corrective Action(s): Corrected at time of inspection.
Date to be Corrected: Corrected at time of inspection.
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: 1 of 2 PIC files reviewed had not been updated to include substantial changes to a PIC’s recreation and leisure care plan that reflect current daytime activities.
Corrective Action(s): Ensure recreation and leisure plans are reviewed and revised due to the current circumstances.
Date to be Corrected: April 23, 2021
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 all food storage areas, the following was observed:
-The downstairs pantry/closet had 2 opened dry goods items that were not sealed and had 2 opened dry goods items that were not labelled with a date of expiration.
- The freezer in the garage had an open bag of bread. (Corrected at time of inspection)
- The upstairs freezer had 1 item that was not dated and 1 item that was not sealed. (Corrected at time of inspection)
- The upstairs fridge had 1 expired condiment (corrected) and a large pot that was not labelled with contents or a date.
- The office pantry/closet had 1 item not labelled and 1 item that was not sealed, labelled, and dated. (Corrected at time of inspection)
Corrective Action(s): Ensure all food is safely stored.
Date to be Corrected: April 23, 2021
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