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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JSAT-CRWLYN

FACILITY NAME
Eden Care Centre
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
CNON-5WG2BK
FACILITY ADDRESS
9100 Charles St
FACILITY PHONE
(604) 792-8166
CITY
Chilliwack
POSTAL CODE
V2P 5K6
MANAGER
Elaine Price

INSPECTION DATE
May 16, 2023
ADDITIONAL INSP. DATE (multi-day)
May 17, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
10
ARRIVAL
09:00 AM
DEPARTURE
03:00 PM
ARRIVAL
11:00 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
87

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 during inspections include: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & Reporting.

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: 32040 - RCR s.37(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: For 2 of 6 staff files reviewed, the staff did not have first aid as required by the job description.
Corrective Action(s): Ensure that staff provide copies of diplomas, certificates or other evidence of the person's training and skills.
Date to be Corrected: May 26, 2023

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 medication room found that some items identified by the pharmacist during the least medication room inspection, have not been corrected. One medication that needs to have the date it was opened written on the medication, was not occurring for at least 2 persons in care receiving that type of medication.
Corrective Action(s): Ensure all employees comply with the policies and procedures of the MSAC.
Date to be Corrected: May 26, 2023

CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: 2 of 5 PICs reviewed did not have documentation of the last time they were seen by a dental health professional.
Corrective Action(s): Ensure all persons in care are encouraged to be examined by a dental health professional at least once per year.
Date to be Corrected: May 26, 2023

CARE AND/OR SUPERVISION: 34590 - RCR s.81(2)(b) - A care plan must be developed, to the extent reasonably practical, (b) in a manner that takes into account the unique abilities, physical, social and emotional needs, and cultural and spiritual preferences of the person in care.
Observation: For 2 of 5 persons in care there was a gate installed in their doorway, however no information about the equipment was included in their care plan.
Corrective Action(s): Ensure care plans are created in a manner that take into account unique needs and abilities, physical, social, emotional needs and preferences.
Date to be Corrected: May 26, 2023

CARE AND/OR SUPERVISION: 34680 - RCR s.81(3)(e)(ii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (ii) a plan for preventing the person in care from falling.
Observation: 3 of 5 persons in care files reviewed did not have a fall care plan.
Corrective Action(s): Ensure all persons who reside in LTC have a fall prevention care plan, which must address a plan for prevention a person in care from falling, and a plan to follow up on any falls suffered by a PIC.
Date to be Corrected: May 26, 2023


Comments

Discussed during inspection:
-Heat planning and heat plans to be implemented as of May 1, 2023
-Upcoming window replacement project. Please submit a health and safety plan at least 2 weeks before the work is planned to begin, and don't begin the project until approval has been received.


It is requested that a written response be submitted on or before May 26, 2023 describing how the above noted contraventions have been appropriately addressed and/or the plan for compliance with legislated requirements. The plan shall include a time line for any items that have not already been addressed. Please note that a follow-up inspection may be conducted to confirm compliance after the written response has been received by Licensing.

Copies of the inspection report and the Facility Risk Assessment Tool were reviewed, discussed, and provided to the Licensee/Manager.

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
May 26, 2023

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