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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-AS4SJD
FACILITY NAME
Kiwanis Care Centre		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
2501021
FACILITY ADDRESS
35 Clute St		FACILITY PHONE
(604) 525-6471
CITY
New Westminster		POSTAL CODE
V3L 1Z5		MANAGER
Lorrie Gerrard
INSPECTION DATE
October 12, 2017		ADDITIONAL INSP. DATE (multi-day)
October 13, 2017		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
9.5
ARRIVAL
02:00 PM		DEPARTURE
05:00 PM		ARRIVAL
09:00 AM		DEPARTURE
03:30 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
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 CCFL website at www.fraserhealth.ca/residentialcare for:
· Additional resources and
· Links to the Legislation (CCALA & RCR)
If you have any questions regarding this report feel free to contact me at 604 949 7710
Contraventions
Previous Inspection - Contraventions observed on FIR #KBOI-A28QSV have been corrected except for those noted on supplementary pages.
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: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Hot water in the recreation area accessible to residents measured over 50.5 degrees Celsius. The water temperature was adjusted to below 49.0 degrees Celsius before the completion of this inspection.
Corrective Action(s): Please provide a plan that will ensure that there is regular monitoring of the hot water system to ensure that residents do not have access to water higher than 49.0 degrees Celsius.
Date to be Corrected: October 27, 2017

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: The laminate counter application to the side of the vanity in room 309 was seen to be loose for approximately 5 inches. This makes sanitation of the area difficult and poses a risk to catch the clothes of residents.
Corrective Action(s): Please provide a plan that ensures that the facility is monitored for the state of repair/maintenance in all areas
Date to be Corrected: October 27, 2017

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31750 - RCR s.35(1)(b) - A licensee must provide the following appropriately furnished and equipped areas: (b) safe and secure locations for medications and the records of persons in care.
Observation: A resident newly admitted for respite was seen to have Fucidin Cream, sennosides and Atrovent at the bedside and in the washroom.
Corrective Action(s): Please provide a plan that will ensure that all residents, including short term residents',medications are stored in a safe secure location.
Date to be Corrected: October 27, 2017

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: Several examples of PRN medications were observed that did not contain documentation of the "results" of the administration of the medication as per PRN Administration Policy.
Corrective Action(s): Please provide a plan that will ensure that for medications administered as a result of the nurses' judgement, will reflect the results of that administration as well as comply with the MSAC Policy.
Date to be Corrected: Oct. 27, 2017

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: Of 2 resident records reviewed, one did not have evidence of immunization status.
Corrective Action(s): Please provide a plan that will ensure that as per the regulation quoted above, that all persons admitted to the facility comply with the Province's Immunization and tuberculosis control programs.
Date to be Corrected: Oct. 27, 2017
Comments

This facility is in the process of changing pharmacy servers. The change will be complete in February of 2018. At that time many of the systems will be updated, and training to professional staff will take place.

The policy for orientation of managers and employees to the Community Care and Assisted Living Act and the Residential Care Regulations was revised and the review of the legislation was added to the orientation check list during the inspection.

The height of one resident was not documented and that of the second resident was reported to change with each measure. different mechanisms were discussed with the DOC (e.g. ulnar and tibial estimates) to arrive at the resident's height. Please provide a plan that will ensure there is an admission height for each resident.

This facility appears very warm and inviting on entrance. The rooms and hallways are clean and uncluttered. There is new wood-looking vinyl flooring in the recreation lounge, a warm orange brown that matches the recreation room floor nearby.

There is a very upbeat atmosphere created by staff and residents as there was conversation and singing observed on both days.

The staff were observed to be smiling and very willing to assist with the inspection. I would like to thank all the staff and residents who participated in this inspection.
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
Oct 27, 2017
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.