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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBEL-CQ4LPB
FACILITY NAME
Rosedale		SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
LBJE-6HXRCG
FACILITY ADDRESS
Removed at operator's request		FACILITY PHONE
Removed at operator's request
CITY
Chilliwack		POSTAL CODE
Removed at operator's request		MANAGER
Removed at operator's request
INSPECTION DATE
March 16, 2023		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
09:30 AM		DEPARTURE
04:30 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
5
Introduction

An unscheduled routine was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). Evidence for this report was based on the licensing officer’s observations, review of the facility records, and information provided by the facility staff at the time of inspection.
The following areas were reviewed:
· Licensing · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing* · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · Records and Reporting

*Staff files were unable to be reviewed as they are not located at the physical facility, a review of those will be completed at a later date at the organizations head office.
As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection, and a 3 year ‘historical’ review of the facility’s compliance and operation.
Visit the CCFL website at https://www.fraserhealth.ca/health-topics-a-to-z/long-term-care-licensing#.XXbB7myos2w for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
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: In a review of the policies and procedures for the medication system in use, the following observations were made:
- One bottle of medication prescribed to a person in care did not have a pharmacy label as required.
- Medications administered on an as needed basis (PRN) require documented follow up, however this did not occur on more than 15 occasions in the last 15 days.
- One medication scheduled to be administered on a previous date was not administered and not returned to pharmacy as required.
- Eight medications were administered however were not signed as administered on the medication administration records (MAR).
- Two medications had more than one dose amount available that could be administered, however it was not documented on the MAR what dose of the medication the persons in care were actually administered in the last 15 days.
Corrective Action(s): Please ensure staff comply with the policies and procedures related to medication.
Date to be Corrected: March 30, 2023

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: The records of two persons in care in were reviewed and the immunization screening forms for both had not been completed on admission.
Corrective Action(s): Please ensure all persons in care comply with the Province's immunization control program.
Date to be Corrected: March 30, 2023

RECORDS AND REPORTING: 39190 - RCR s.78(2)(a) - A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care.
Observation: The Medication Administration Records (MAR) for persons in care (PIC) were reviewed and it was observed that all medications prescribed that require administration by a Pharmacist were not documented on the MAR and no record of the medications administered by the Pharmacist was retained on site.
Corrective Action(s): The MAR must include a record of medications prescribed and administered to PICs. This record is to be retained at the facility.
Date to be Corrected: March 30, 2023
Comments

Observations made and the contraventions identified were reviewed with the facility manager at the time of the inspection. A copy of this inspection record and the risk assessment was provided after the inspection as additional information was required. The reports were provided electronically and no signature was collected.

Please ensure to post in a prominent place in the facility a copy of this inspection report.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Mar 30, 2023
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.