Dufferin Group Home
1423 Mt Dufferin Dr Kamloops BC V2E 1A1 · Residential Care - Licensing
9 inspections
- Routine Inspection Follow-up
1 infraction
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): The system to 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 continues to meet the requirements of this regulation, is ineffective. On a review of three staff files, the performance review for one staff member was not completed on an annual basis as directed by facility policy. The system to ensure that employees are responsible for the preparation and delivery of food receive ongoing education respecting the preparation and delivery of food, nutrition and, if required, assisted eating techniques, is ineffective. On a review of three staff files, the ongoing education respecting the preparation and delivery of food, for one staff member, was not completed at the frequency directed by facility policy.
- R3.1N - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- R3.1U - Ensure employees responsible for the preparation and delivery of food receive ongoing education respecting the preparation and delivery of food, nutrition, and if required, assisted eating techniques; 44 ( 1 )(b)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Routine Inspection
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The system to ensure that a licensee provides secure, safe and adequate storage areas for cleaning agents is ineffective. Cleaning agents were observed in an unlocked kitchen cupboard, accessible to persons in care.
- R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Routine Inspection
4 infractions
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): The facility had changed from their previous emergency supply plan to obtaining a 30 year kit. The 30 year kit was not found to be present in the facility at the time of the inspection. *This is a repeated contravention On one MAR, there were 4 missing "effectiveness of PRN" documented, as per facility policy. It was noted on several entries for the "effectiveness of PRN" staff were recording "somewhat effective" which does not indicate clearly if the medication was effective or not.
- R2.1G - Have a plan that sets out how persons in care will continue to be cared for in the event of an emergency; 51( 1 )(b)
- R2.1N - Establish and review policies and procedures on safe and effective storage, handling and administration of medications; 68( 3 )(b)(i)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Snacks included on the daily menu showed only one food group per offering of snack at each instance, twice per day.
- R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): Within the pantry where an assortment of packaged foods were present, there were two food items in bags which had holes present and appeared to have evidence of a rodent having been in the pantry at some point. The staff removed items immediately and made an immediate plan to remove all items and clean the pantry. Please provide within your compliance plan a process by which you will monitor the pantry and other food storage areas for possible undesirable contaminants of food items.
- R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Water temperatures were measured at 52.5 degrees Celsius in one bathroom, and measured at 51.7 degrees in another bathroom. Window frame in one bedroom was noted to have gouges measuring approximately 4cm long, 1cm wide, and 0.5cm deep with splintered wood present in this same area, and around the frame there were many areas of peeling paint present as well. In the backyard, the retaining wall made of wooden railroad ties, and chain-link fence have several areas where the railway ties have been pushed into the yard and dirt is spilling into the yard from the property above. In one bedroom, the sliding door is not easily opened for the person in care to exit to the outside/use the door for room ventilation. The cement pad outside on the main level is broken and crumbling in many areas leaving areas of loose stones/cement. One bedroom window was unable to be opened due to an outdoor window shade blocking the window from being able to open, as the shade was hanging lower than it was intended to when installed.
- R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
- R7.1X - Bedroom windows must be opened easily for ventilation, unless it would be unsuitable to the health, safety or dignity of the occupant or, the facility is equipped with an air conditioning system or mechanical ventilating system; 28 ( 2 )(a)(b)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Routine Inspection
4 infractions
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): Review the emergency kit process, including PIC personal bags as well as facility emergency provisions. Please inform licensing on what changes have been made to the process including how often the emergency supplies will be audited, and who will be responsible for the audits.
- R2.1G - Have a plan that sets out how persons in care will continue to be cared for in the event of an emergency; 51( 1 )(b)
- R4.6 - Are facility records current and complete?
- Observation(s): Menu substitutions were last noted in October 2020, it was discussed during this inspection that substitutions had been made to the menu since that point.
- R4.6C - Retain food services records of menus and menu substitutions; 87(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The back deck has peeling paint throughout most of the surface area, the railing to the deck also has peeling paint and is in a poor state of repair in one particular section that was discussed during this inspection. The BBQ and propane tank on the back deck are currently accessible to a PIC's.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): One PIC has a nutritional care plan that allows for food not on the main facility menu, please develop a process to document the food intake for this PIC for review if Needed/required.
- R10.3N - Develop a nutrition plan for each person in care and review the plan on a regular basis (Applies to a facility with 24 or fewer persons in care); 83( 1 )(a)( 3 )(a)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Routine Inspection
2 infractions
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): Facility has a system in place to monitor fridge and freezer temperatures, at the time of this inspection the freezer temperature charted for the past few weeks did not fall within the optimum temperature for frozen food storage. Inform Licensing on what systems are in place for following up with temperature checks.
- R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): A cleaner was observed as accessible in a shared PIC/staff washroom. The cleaner was removed at the time of the inspection. Inform Licensing on what systems are in place to ensure PIC's do not have access to potentially hazardous materials.
- R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Routine Inspection
2 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The facility has a system in place for Occupational Health and Safety audits, however, it doesn't seem to include wear and tear to the facility, including timelines for addressing these items (ie. deck is in disrepair, dent in bathroom wall, scratches on wall in living room downstairs)
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Fluorescent light in laundry room noted to not have a cover. Persons in care may have access inside the laundry room when staff are present.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Monitoring
3 infractions
- RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
- Observation(s): A home alone care plan was observed during this inspection as incomplete. Ensure home alone care plans include specific information regarding who was involved in developing the care plan? How often the plan will be reviewed? What steps were taken by the facility to determine if a home alone care plan was appropriate? Home alone plans should detail instructions for staff regarding when they are able to utilize and include any steps to be taken when staff leave the facility.
- RB1.23A - Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Ice build-up observed outside of one facility exit, ice also noted on the stairs off the back deck and the pathway from the back deck to the fence gate. ensure all of these areas are cleared of ice. In your response also include what monitoring systems will be put in place to ensure all exits are kept free of all obstructions including ice.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): A home alone care plan was observed during this inspection as incomplete. Ensure home alone care plans include specific information regarding who was involved in developing the care plan? How often the plan will be reviewed? What steps were taken by the facility to determine if a home alone care plan was appropriate? Home alone plans should detail instructions for staff regarding when they are able to utilize and include any steps to be taken when staff leave the facility.
- R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
- RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
- Monitoring
2 infractions
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Some strategies are in place specific to a PIC to help prevent falls, ensure this information is included in the care plan and updated as required or needed.
- R10.4P - Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (Show More)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): The picture in one PIC's "face sheet" was dark and hard to see, ensure the picture is updated in case it is needed during an emergency.
- R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Monitoring
3 infractions
- 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Facility self monitoring plan includes monthly checks, only November 2015 documented, if the plan is to conduct checks monthly ensure they are documented,. Please expand checks to include additional areas such as: MAR reviews, emergency exits, staff daily charting reviews etc.... If issues are noted during checks please include plans for correction. Self monitoring checks should be available for review during licensing inspections.
- Regularly monitor the physical environment and the care and services provided; 61
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): The weights for one PIC were not charted every month in 2015, ensure each PIC is weighed at least monthly (or more if required in nutritional care plan). The weights should be charted and reviewed to determine if action is needed due to significant weight loss or gain.
- Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Emergency exit through the garage was blocked with boxes at the time of inspection, boxes removed during inspection. Ensure emergency exits are always kept clear. Wall surrounding bathtub in upstairs washroom is in poor state of repair (breaks in wall board), ensure this area is replaced or repaired. Inform Licensing in writing on when/how this infraction will be corrected.
- Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
- 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?