LICENSING: 30060 - RCR s 8(3)(b) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (b) replace the manager, either by hiring a person who, or using a hiring process that, is approved in writing by the medical health officer.
Observation: The manager on record was reported to have been absent from the facility since October 2020. A temporary manager was responsible for overseeing the facility; however, the ongoing absence of the manager on record was not communicated to the geographic LO and written approval for a temporary manager was not obtained by the licensee.
Corrective Action(s): Ensure facility manager absences greater than 30 days are reported to CCFL and that the licensee assigns a manager (temporary or permanent) to oversee the day to day operation of the facility who has been approved in writing by CCFL.
Date to be Corrected: Corrected at time of inspection.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: (REPEAT CONTRAVENTION) The hot water was measured to be 53.5°C at the sink in the main bathroom, 51.5°C in the downstairs ensuite, and 52.5°C in the upstairs ensuite.
Corrective Action(s): Ensure water accessible to a person in care, from any source, is not heated to more than 49°C.
Date to be Corrected: May 21, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: (REPEAT CONTRAVENTION) There were a number of gaming equipment cords unsecured in the downstairs bedroom that were a possible tripping hazard.
Corrective Action(s): Ensure electrical and gaming cords are safely secured and stored.
Date to be Corrected: May 21, 2021
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: (REPEAT CONTRAVENTION) Approximately 80% of the stain on the back deck rails and boards was eroded and 8 deck boards were partially rotten and loose.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: June 4, 2021
STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: (REPEAT CONTRAVENTION) 4 employee file records were reviewed. 1 of 4 employee files contained no record of tuberculosis screening. Additionally, the licensee-generated record of immunization form in use does not include a documented record of poliomyelitis.
Corrective Action(s): Ensure that staff have provided evidence on hire of compliance to BC's immunization and tuberculosis programs.
Date to be Corrected: June 4, 2021
STAFFING: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: 4 employee files were reviewed. Performance reviews were last completed in 2019 for 3 of 4 staff. Licensee policy stated that performance reviews are to occur annually.
Corrective Action(s): Ensure the performance of each employee is reviewed annually, as per facility policy, to ensure that employees continue to
meet regulatory requirements and to ensure competence for assigned duties.
Date to be Corrected: June 4, 2021
STAFFING: 32360 - RCR s.92(3)(a) - A licensee must keep (a) in the case of employees, all records required under section 37 (1) [character and skill requirements] for the entire time that the subject of the records is an employee of the community care facility.
Observation: 4 employee file records were reviewed. 1 of 4 employee files contained no record regarding employee character (character references).
Corrective Action(s): Ensure employee files contain a record of character references for the staff's entire time of employ at the facility.
Date to be Corrected: June 4, 2021
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: Upon review of the facility's emergency supplies and emergency procedures, it was observed that the amount of water in the emergency supply kit was insufficient to support persons in care and staff for a period of 3 days and that emergency contact information had not been updated to reflect a change in management contact information.
Corrective Action(s): Ensure that emergency supplies are adequate to support persons in care and staff for 3 days and that emergency response
information remains current.
Date to be Corrected: May 21, 2021
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: 2 of 4 persons in care records were reviewed. 2 of 2 care plans reviews were last completed in 2018.
Corrective Action(s): Ensure each care plan is reviewed and, if necessary, modified at least once each year.
Date to be Corrected: June 4, 2021
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: One expired oral medication was stored with current medications.
Corrective Action(s): Ensure expired medications are returned to the pharmacist.
Date to be Corrected: Corrected at time of inspection.
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: It was observed that menus offered fewer daily servings of fruits/vegetables and grains than recommended as per Canada's Food Guide. Management indicated that menus are in the process of revision and auditing.
Corrective Action(s): Ensure all menus offer the minimum number of required servings based upon Canada's Food Guide (2007).
Date to be Corrected: June 4, 2021
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