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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-CP5Q36

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 16, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7.5
ARRIVAL
09:30 AM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
33

Introduction

This is a unscheduled routine inspection to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.) and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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 the inspection.

The following areas were reviewed:

- Licensing
- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting

As part of this 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/licensed-care-facilities-and-assisted-living-providers#.YrT9QyfMI2w for:

- Additional resources, and
- Links to the legislation (C.C.A.L.A. and R.C.R.).

Contraventions
Previous Inspection - Not Applicable
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: The facility has an on-going maintenance plan in-place. During the walkthrough of the facility indicated the right corner wall entrance to the small dining area with chips in the corner of the wall.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: February 28, 2023


Comments

Persons in care records:

- The Director of Care appears to have thorough systems in-place which include auditing the care flow sheets for the persons in care and follows up any issues that are noted.

Medications:

- The Director of Care appears to have thorough systems in-place which include auditing systems such as medications including PRN (as needed) medications documentation including the results/effect/outcome and so on.

Staffing:

- In discussion with the Recreation Manager they are in the process of gathering for the volunteer files the following documentation

* Tuberculosis clearance (The TB and Immunization Guideline for Staff can be used which has a standardized tuberculosis form).

* Immunizations (The TB and Immunization Guideline for Staff can be used which has a standardized immunizations form).

* References.

* Currently criminal record checks are being completed through the local police detachment. The site management will review which process they want to continue as criminal record checks through the Ministry for Public Safety and Solicitor General.

Please refer to the following website for reference:

https://www2.gov.bc.ca/gov/content/safety/crime-prevention/criminal-record-check/volunteer-organizations

When responding to this routine inspection report, please let the Licensing Officer when it can be anticipated all documentation will be in-place.

Nutrition and Food Services:

- The facility dietitian will be providing two inservices which include dysphagia and feeding with dignity (which will cover assisted feeding techniques). The Licensing Officer sent resources around continuing education for food service employees and sample education schedules to guide the facility management as well.

When responding to this inspection report, please let the Licensing Officer know when the inservices will be provided and if anything additional will be provided as well after reviewing the resources sent by the Licensing Officer.

Thank you to everyone at Willow Manor Care Centre for their time in completing this routine inspection. If there are any questions related to this routine inspection report, please contact the Licensing Officer that completed 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
Feb 24, 2023

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