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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
MMON-C8DR2N

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

INSPECTION DATE
October 20, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6.25
ARRIVAL
09:00 AM
DEPARTURE
03:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up
# OBSERVED IN CARE

Introduction

A follow up inspection to Routine Inspection MMON-C3YNVQ was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP).

The following care systems were reviewed during this inspection:
- Physical Facility
- Staffing
- Care and Supervision
- Medication
-Hygiene and Communicable Disease
-Records and Reporting

Staffing was unable to be reviewed during this inspection as all staff files have been sent to the Head Office of the Organization, for review by the organization. Staff files will be reviewed at a later date by Licensing Officer.

For resources for licensees, links to the Legislation (CCALA and RCR), and Residential Care Facility Inspection Reports posted online go to: www.fraserhealth.ca/residentialcare

Contraventions
Previous Inspection -
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: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: It was observed in two person in care’s rooms there was broken drywall on the bulkhead corner leading the toileting area. It was observed in three person in care’s rooms there were broken or bent slats in their window blinds. It was also observed that there were plug in covers that had been removed in the hallway of one area of the building, leaving wires beneath exposed.
It was discussed with manager that each of these physical facility issues have been sent to the maintenance department.
Corrective Action(s): Ensure all rooms and common areas are in a good state of repair.
Date to be Corrected: November 12, 2021

CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: Five persons in care’s care plans were reviewed and it was observed that Activities of Daily Living (ADL) forms in two person in care’s rooms did not contain specific information from the care plan to guide staff in providing care to the persons in care. In one of the two person in care's care plans, the number of care staff required for transfers was not consistent. One person in care’s care plan had not been updated to reflect changes in that persons mobility
This is a repeat contravention from MMON-C3YNVQ.
Corrective Action(s): The licensee must ensure that the care and supervision of persons in care is consistent with the terms and conditions of the person in care’s care plan.
Date to be Corrected: November 12, 2021

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: On review of five person in care’s immunization and tuberculosis screening documentation, it was observed that two tuberculosis screening documents were present but incomplete. This is a repeat contravention from MMON-C3YNVQ.
Corrective Action(s): Licensee to ensure forms are completed in their entirety as per the provincial immunization and tuberculosis control programs.
Date to be Corrected: November 30, 2021

MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: On review of the medication rooms, it was noted one packaged medication was not in a container or box, and had no pharmacy label affixed. This is a repeat contravention from MMON-C3YNVQ.
Corrective Action(s): Ensure all medications are in packages/boxes with a pharmacy provided label
Date to be Corrected: November 12, 2021


Comments

It was discussed that the facility is undergoing a transition to a new pharmacy on November 1, 2021 and will have new policies and procedures relating to medications after this date. These were not reviewed during this inspection as they did not relate directly to contraventions from the annual inspection. These policies and procedures will be subject to review at the next annual inspection.
It is requested that a written response be submitted on or before November 12, 2021, describing how the above noted contraventions have been appropriately addressed and/or the plan for compliance with legislated information. The plan shall include a timeline for any items that have not already been addressed.
Copies of the follow up inspection report 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
Nov 12, 2021

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