Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-BC7MT2
FACILITY NAME
Bradley Centre		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962MVC
FACILITY ADDRESS
45600 Menholm Rd		FACILITY PHONE
(604) 795-4103
CITY
Chilliwack		POSTAL CODE
V2P 1P7		MANAGER
Kim Norman
INSPECTION DATE
May 14, 2019		ADDITIONAL INSP. DATE (multi-day)
May 15, 2019		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8.5
ARRIVAL
11:30 AM		DEPARTURE
03:00 PM		ARRIVAL
11:00 AM		DEPARTURE
04:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed include the following:

Licensing
Physical Facility
Staffing
Policies and Procedures
Care and Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records & Reporting
Resident Bill of Rights
Additional CCALA Sections

As part of the 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 www.fraserhealth.ca/residentialcare for additional resources and links to the legislation (CCALA & 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: Review of the MAR for Vedder wing found 10 signatures missing for medications administered. Also no record of effectiveness documented for 5 PRN medications administered.
Corrective Action(s): Ensure that employees comply with all policies and procedures related to medication administration and documentation.
Date to be Corrected: 24 May 2019

CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: Review of 4 PIC's record found that 1 recreation plan had not been reviewed in over a year. Review of records in the recreation department found that over 10 percent of PIC's did not have an assessment completed to develop a recreation/leisure plan.
Corrective Action(s): Ensure that a care plan includes a recreation and leisure plan.
Date to be Corrected: 14 June 2019

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Inspection of the refrigerator in the dining lounge, used by PICs, found there to be 2 food items that were not labelled or dated.
Corrective Action(s): Ensure that all food is safely and securely stored.
Date to be Corrected: 15 May 2019
Comments

The Community Care and Assisted Living Actand pursuant Residential Care Regulationset the minimum standards that must be met by all licensees of licensed care facilities to ensure the health and safety of vulnerable individuals in care. The responsibility rests with Bradley Center to provide for the health and safety needs of all individuals in your care at all times.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.