Roalshary
558 73 Ave Grand Forks BC V0H 1H0 · Residential Care - Licensing
8 inspections
- Routine Inspection
0 infractions
- 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 door molding of a person in care's bedroom is damaged from a wheelchair. The door to the room is scheduled to be replaced due to bent hinges. One of the floor tiles in dining area adjacent to this bedroom is worn out and taped over.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Routine Inspection
1 infraction
- 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): Health care plans had not been updated since April 2022 as per the date on the document.
- R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Routine Inspection
2 infractions
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): The laundry facilities that are used by persons in care did not have a slip resistant floor surface.
- R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): It was identified during the inspection that cleaning chemicals were located in an unlocked 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)
- R7.2 - Is the environment maintained to prevent falls?
- Routine Inspection
0 infractions
- Monitoring
1 infraction
- 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): The current system for ensuring all care plans are reviewed/revised, at minimum annually, appears to be ineffective. LO noted documents in resident's binders which guide staff in care provision that were dated March 2014.
- R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Monitoring
5 infractions
- 2.1 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): It was observed while reviewing the Policy and Procedure manual that some policies and procedures have not been reviewed within the past year. Some policy review dates noted went as far back as 2011 (review dates ranged from 2011 to 2015).
- Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): Unable to locate the immunization status of persons in care when reviewing their care plans. On one person in care's care plan, there was no indication as to the person being weighed or reason for not being weighed for two months (April and May 2016).
- Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78( 1 )(a) Director of Licensing Standards of Practice: Immunization records
- Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
- 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): Personal care products of persons in care (toothbrushes, toothpaste, nail clippers, etc) were stored together in the shared bathroom (on the countertop and in a drawer of the vanity).
- Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Hot water temperature was tested in the bathrooms on both sides of the facility. On one side the temperature read 51 degrees Celsius and on the other it read 58 degrees Celsius. Licensing Officer requested immediate action be taken to rectify this concern. Manager to report to Licensing by Wednesday next week (August 24, 2016 at the latest) as to what actions were taken. The one bathroom has damage on the walls in the one corner adjacent to the toilet and is missing moulding by the bathtub (exposing drywall in places). The following was corrected at time of inspection: furnace room was noted as unlocked and accessible to persons in care; and, sharp knives and scissors found to be accessible in the kitchen.
- Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- 9.1 Are medications stored, handled, and administered appropriately?
- Observation(s): The Medication Safety and Advisory Committee has not met since before July 2015 (which includes the medication inspection, policy review, and person in care's medication reviews).
- Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)
- Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(b)
- 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Monitoring
5 infractions
- 4.5 Are incidents and notifications reported and records retained as required?
- Observation(s): LO noted that one of the bathrooms was under repair due to a leak. This is a "Service Delivery Problem" and falls under the "reportable Incidents" listed in Schedule D of the Residential Care Regulation. Please submit an incident report. Please respond to LO as to how failure to report will be addressed moving forward by the above date.
- Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77(2)(c)
- 7.2 Is the environment maintained to prevent falls?
- Observation(s): Both laundry areas are missing "non-slip' flooring. If residents can access the laundry area, ensure that there is a non-slip surface on the floor.
- Laundry facilities must have a slip resistant floor surface if used by persons in care; 35(2)(a)
- 2.1 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): LO noted a discrepancy with the medication policy. The medication administration policy in the MAR was dated 2013 and the medication policy in the Policy and Procedure binder was dated 2014. This is an outstanding contravention from the previous inspection.
- Review and, if necessary, revise policies and procedures at least once a year; 85(1)(b)
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): One resident did not have a photo in their chart.
- 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)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The wall in one of the dining rooms has some damage. The wall is chipped and the paint is missing.
- Maintain all rooms and common areas in a good state of repair; 22(1)(b)
- 4.5 Are incidents and notifications reported and records retained as required?