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: Licensing observed the following concerns in common areas:
A section of fence missing (1.8m wide)
Six lower kitchen cupboard doors blackened due to possible rot and the coating over the wood had worn off
Wood lining the base of the lower kitchen cupboards was blackened due to possible rot
The PIC washroom had cracked tile (30 cm x 30 cm) and mold surrounding bathtub base.
(Repeat contravention from Routine Inspection KPRK-CBRRDV dated February 4, 2022).
Corrective Action(s): Ensure rooms and common areas maintained in a good stated of repair.
Date to be Corrected: August 31, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Licensing observed a tree with fallen branches in proximity to the home. Caution tape was placed under the tree’s canopy. Thorny bushes within the fence line were accessible to PICs.
Ensure common areas are maintained in safe and clean condition.
Corrective Action(s): Ensure common areas are maintained in safe and clean condition.
Date to be Corrected: August 31, 2022
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: Staff did not comply with an MSAC policy five time in the past two months. As a result, systems for reviewing incidents were not initiated.
Corrective Action(s): Ensure employees comply with MSAC policies and procedures.
Date to be Corrected: July 25, 2022
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: In the past year one PIC had not received routine medical check-ups as outlined in the care plan. Changes from the PIC's health measurements were noted in the past five months.
Corrective Action(s): Ensure care plans are implemented.
Date to be Corrected: August 8, 2022
MEDICATION: 36060 - RCR s.68(2)(c) - A licensee must appoint a supervising pharmacist to (c) consult with employees respecting medication interactions and other problems related to medication.
Observation: Records of consultation with the pharmacist were not available (medication safety and advisory committee meeting, onsite medication reviews). Related legislation: Health Professional Act, Bylaws, Schedule F Part 3 (Repeat contravention from Routine Inspection KPRK-CBRRDV dated February 4, 2022).
Corrective Action(s): Ensure the pharmacist consults with employees regarding medication interactions and problems.
Date to be Corrected: August 8, 2022
MEDICATION: 36130 - RCR s.70(4)(a) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (a) approved by the medication safety and advisory committee and the medical practitioner or nurse practitioner who prescribed or ordered the medication.
Observation: Self-administration plans for three medications had not been approved by an authorized health professional and the MSAC. RCR s.69(3)(b) regarding medication storage also requires consideration in the plans.
Corrective Action(s): Ensure medication self-administration plans are approved my authorized health professionals and the MSAC.
Date to be Corrected: August 8, 2022
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: In the past five months, six out of the twelve menu substitutions were not of the same food group or included fewer food groups than the meal being replaced.
Corrective Action(s): Ensure substitutions are from the same food group and have similar nutritional value.
Date to be Corrected: July 25, 2022
NUTRITION AND FOOD SERVICES: 37100 - RCR s.62(3) - The licensee must take all reasonable steps to ensure that the food served to persons in care follows the menu and, if unable to do so because of unforeseen circumstances, that the food provided to persons in care meets the nutritional requirements set out in subsection 62(2).
Observation: Over a four month period, menus were not followed for at least one meal per day. Three PICs required packed lunches regularly which were not part of the menu.
Corrective Action(s): Ensure reasonable steps are taken to follow the menu and nutritional requirements are met.
Date to be Corrected: August 8, 2022
RECORDS AND REPORTING: 39400 - RCR s.85(3) - A licensee must keep a copy of each policy and procedure of the medication safety and advisory committee.
Observation: Written policies were not available regarding leaves of absence and self-administration.
Corrective Action(s): Ensure a copy of the MSAC policies are available to staff.
Date to be Corrected: August 2, 2022
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