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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SRAO-BJRUFX
FACILITY NAME
Eagle Ridge Manor		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962L73
FACILITY ADDRESS
475 Guildford Way		FACILITY PHONE
(604) 469-3211
CITY
Port Moody		POSTAL CODE
V3H 3W9		MANAGER
Gail Jang
INSPECTION DATE
December 10, 2019		ADDITIONAL INSP. DATE (multi-day)
December 12, 2019		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
10:00 AM		DEPARTURE
03:30 PM		ARRIVAL
10:00 AM		DEPARTURE
12:30 PM		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). 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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo 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
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: For 2 PICs it was noted that the effects of the prn medication was not docuemented. FH policy on medication administration states that a client's response to treatment should be documented.
Corrective Action(s): Please ensure the FH medication administration is being followed by staff.
Date to be Corrected:

CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: In 3/6 PIC charts reviewed a care plan for recreation was not noted in the interdisciplinary care plan. This included one PIC who was admitted in March 2019.
Corrective Action(s): Please ensure each PIC's care plan includes a recreation and leisure plan.
Date to be Corrected:

CARE AND/OR SUPERVISION: 34900 - RCR s.83(5)(a) - If a person in care refuses or is unable to be weighed, the licensee must (a) record in the nutrition plan of the person in care the reason why the person in care was not weighed.
Observation: In 2/6 PIC charts reviewed it was noted that there was one missing weight in each chart without a reason identified.
Corrective Action(s): Please ensure that the reason a PIC was not weighed is recorded in the weight chart.
Date to be Corrected:

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: In 2/6 PIC charts reviewed it was noted that the PICs' immunization status form was not completed. Both PICs were admitted within the past 2 years.
Corrective Action(s): Please ensure that all PICs admitted to the facility have their immunization status reviewed upon admission.
Date to be Corrected:

HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Two tub rooms were inspected. One tub room had several tubes of toothpaste not labelled in a drawer. In another tub room there were brushes and combs in a container with no label. A toothbrush was also noted on the cart with no identification.
Corrective Action(s): Please ensure that grooming supplies and oral care supplies are labelled and kept in the PICs' rooms.
Date to be Corrected:

MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation (CORRECTED DURING INSPECTION): A insulin vial with an expired date was noted in the fridge of the medication room.
Corrective Action(s): Please ensure that expired medication is returned to the dispensing pharmacy.
Date to be Corrected:


Comments

The facility was provided with resources to assist with the implementation of online RI reporting. Licensing would like to thank the staff for their time and assistance.

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
Jan 31, 2020
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.