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
NBIH-BM7TLL

FACILITY NAME
Willow Manor Care Centre
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
PWIN-6MEN2V
FACILITY ADDRESS
12275 224th St
FACILITY PHONE
(604) 466-8602
CITY
Maple Ridge
POSTAL CODE
V2X 6H5
MANAGER
Niki Tupper

INSPECTION DATE
February 27, 2020
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
5.5
ARRIVAL
09:30 AM
DEPARTURE
03:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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
· Physical Facility
· Staffing
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and 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 Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo

Contraventions
Previous Inspection - Contraventions observed on FIR #CJOS-BAHS28 have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: 1 PIC's inhaler spacer was not being cleaned on a regular basis. Nursing guidelines state that the spacer should be cleaned at least once per week.
Corrective Action(s): Please ensure that all equipment is maintained in a clean condition.
Date to be Corrected: March 31 2020

STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: The facility has a number of staff with no current first aid. The manager stated that they don't require their nursing staff to have a separate first aid certification.
Corrective Action(s): Please ensure that PIC's have at all time immediate access to an employee who holds a valid first aid and CPR certificate.
Date to be Corrected: June 30 2020

POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: 1/3 PIC's restraint agreements had no written consent from the representative. Verbal consent had been given but the representative did not sign the consent form.
Corrective Action(s): Please ensure that written agreement is given by the PIC's representative for any restraints in use.
Date to be Corrected: March 31 2020.

POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: 1/3 restraint agreements reviewed had no written consent by the medical practitioner. Verbal consent had been given but the Doctor did not sign the form.
Corrective Action(s): Please ensure that there is written agreement in place from the medical practitioner for the use of a restraint.
Date to be Corrected: March 31 2020


Comments

The nutrition audits were unable to be reviewed at the time of the inspection as they are kept with the dietitian who is only on-site once every 2 weeks. Licensing will contact the DOC to arrange a follow up inspection to review these within 3 months.

Wound care plans were reviewed and seemed to be follow up appropriately. However Licensing had one recommendation for the treatment plans; the frequency of the care should be added to the plan.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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