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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

NTJN-BTRQA9

FACILITY NAME Maple Ridge Seniors Village		SERVICE TYPES 130 Long Term Care	FACILITY LICENSE # LSEO-AG9VR4
FACILITY ADDRESS 22141 119th Ave			FACILITY PHONE ()
CITY	POSTAL CODE		MANAGER Jane Redoblado

INSPECTION DATE September 24, 2020	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3
ARRIVAL 10:15 AM	DEPARTURE 01:15 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Follow-up					# OBSERVED IN CARE

Introduction

An unscheduled inspection was conducted as follow up to the routine inspection #NTJN-BN8RCB conducted on March 5, March 6, and March 13, 2020. This unscheduled follow up was conducted independently by Licensing for follow to # conducted on March 27, 2020 and # on June 4, June 5, and June 15, 2020. Teleconference meetings were held with Maple Ridge Senior's Leadership bi-weekly and then quarterly, as these meetings updated Licensing and LTCS on the progress of the facilities compliance plans.

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: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored. Observation: A review of one persons in care room found one prescribed topical item was located in the person in care's bathroom cabinet. It was determined by the facility DOC and ADOC that this item should be secured in the medication storage room. Corrective Action(s): Ensure that all medications in the community care facility are safely and securely stored. Date to be Corrected: October 19, 2020 STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation. Observation: Review of the performance reviews determined that reviews were still not completed for all current staff. It was determined that leadership changes have delayed the completion of the staff reviews. Corrective Action(s): Ensure that the performance of each employee is reviewed both regularly and to ensure that the employee continues to meet the requirements of this regulation. Date to be Corrected: October 19, 2020 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: Review of the narcotic counts and the facility MSAC policies and procedures determined that employees were not complying with the policy regarding narcotic counts and two signatures. It was confirmed that employees were not double signing narcotics as the staff was working a longer shift and was working overtime when the counts were to be completed. It was determined that staff were administering medications past the identified administration time frames as directed by the pharmacist. Corrective Action(s): It was discussed that staff will completed the counts and sign for both when working overtime and the policy will be reviewed to determine if it needs changing. DOC will review the administration times frames with staff. Date to be Corrected: October 19, 2020 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: Review of 1 of 6 tub rooms found a personal shampoo bottle that had no label identifying which person in care it belonged to. Corrective Action(s): Ensure that all personal items identify which person in care the items belong too, to assist person in care in maintaining health and hygiene. Date to be Corrected: October 19, 2020

Comments

Ongoing monitoring for this site by Fraser Health's Licensing and Quality Assurance teams will continue to occur.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Oct 12, 2020

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