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Knutsford Group Home

3161 Merritt Princeton Highway 5A Knutsford BC V0E 2A0 · Residential Care - Licensing

8 inspections

  1. 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 four 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 four 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)
  2. Routine Inspection

    4 infractions

    • 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 all employees comply with the policies and procedures of the medication safety and advisory committee is ineffective as demonstrated by the following: - It was observed that the direction for the use of one medication, for three persons in care, varied from the prescribed frequency of which the medication was administered and documented by staff. - It was observed that a PRN (as needed) medication was documented on the PRN medication chart but was not signed for on the MAR (medication administration record) sheet.
      • R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system to ensure that each person in care is weighed at least once each month is ineffective. On review of monthly weights for persons in care, there were several monthly weights missing with no indication of refusal to be weighed. *This is an ongoing contravention.
      • R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 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 all rooms and common areas are maintained in a good state of repair is ineffective. It was observed that several areas of the facility require maintenance, including but not limited to the following: - Hole in one person in care's closet door. - Various holes in walls. - Bathroom cupboard door missing. - Broken pieces to bedroom door frame and door. - Paint wearing on trim work on main floor. - Peeling paint to exterior window frames on backside of facility. - Rust to metal handrails at front stairs of facility. The system to ensure that a licensee provides secure, safe and adequate storage for cleaning agents, chemical products and other hazardous materials is ineffective. It was observed that a staff member's prescription medication container was accessible to persons in care. *Corrected during inspection.
      • 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)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The system to ensure that a person in care's medication is returned to the dispensing pharmacy if the expiry date on the medication has passed is ineffective. A review of persons in care's medications identified one roll of medication which had expired.
      • R9.1I - Medications must be returned to the dispensing pharmacy if the person in care is no longer taking the medication or if the medication has expired; 72(a)(b)
  3. Routine Inspection

    4 infractions

    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): There was no evidence of documentation for two months of weights/refusals for one person in care, over a one year period. Please ensure there is a process for persons in care to be weighed on a monthly basis, which also includes refusals to be weighed, and persons responsible to ensure this is being done on a monthly basis.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Observed during inspection for menus: -A review of menus available showed that for all snacks, there was only one food group planned for. Staff inform they often provide additional food items to ensure persons in care have enough to eat, but this was not indicated on the menus provided -During the inspection, it was discussed that the approved menus have not been reviewed or updated for at least four or more years. At the time of inspection, the menus ran on a four week rotation, with a fall/winter and spring/summer set. Staff commented they often need to adjust how the foods prepared are presented due to a variety of reasons and the lack of change in menus. An example was Chicken stir fry on the menu might be presented as chicken, rice and veggies separately, and not as a "stir fry". -A substitutions list was available, but had not been a tool that was used. During discussion, it was apparent staff were not aware of what defined a "substitution" that was required to be added to the list.
      • 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)
      • R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): One person in care's bedroom had broken molding missing from the wall, which has been reported and planned to be replaced, however, there were 2 nails sticking out which were a safety concern. This was corrected during inspection.
      • 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 review of care plans did not show any evidence of oral care plans present. A review of care plans did not show any evidence of nutrition care plans present.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
      • R10.3E - Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)
  4. Routine Inspection

    3 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): As PIC's help with laundry, please ensure a slip resistant surface is in place.
      • R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Facility has a procedure in place for monitoring fridge temperatures, some of the temperatures observed (6-8 degrees Celsius) as charted recently did not fall in the desired zone (0-4 degrees Celsius), no information was available on what steps were taken to follow-up on the noted temperatures.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Persons in care at the home have ID, however when it was viewed at the time of this inspection the emergency contact information noted on the card was incorrect.
      • R10.2M - Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56( 3 )(a)(b) (Show More)
  5. Routine Inspection

    1 infraction

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Light fixture cover missing in PIC bedroom closet.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  6. Monitoring

    0 infractions

  7. Monitoring

    2 infractions

    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): One of the staff files reviewed during this inspection did not include copies of completed reference checks. Please inform Licensing that the reference checks have been completed and that the hiring/auditing procedures have been reviewed to ensure all required documentation is available for staff files.
      • Keep employee character references; 86(b)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): PIC's do carry BC ID when on outings with the program, PIC's also usually carry a house ID which indicates the persons name, the facility name and a contact number, during this inspection one of the PIC's did not have this card. Ensure auditing procedures include a plan to ensure all PIC's have ID during outings.
      • Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56( 3 )(a)(b)
  8. Monitoring

    2 infractions

    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Licensing reviewed menu substitutions during this inspection and noted on three occasions when a meat sandwich (turkey, roast beef)was replaced with peanut butter and jelly.
      • Provide substitutions from the same food group and have a similar nutritional value; 62( 2 )(d)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Medication cabinet door was found unlocked during this inspection, cabinet was then locked during the inspection. Ensure all staff are aware of facility procedures to keep medications inaccessible to PIC's at all times.
      • Ensure all medications are safely and securely stored; 69( 3 )(a)