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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

AKUR-CNPRZE

FACILITY NAME Cascade Gardens		SERVICE TYPES 130 Long Term Care	FACILITY LICENSE # LOLA-A3YMEM
FACILITY ADDRESS 3460 Kalyk Ave			FACILITY PHONE (604) 434-2666
CITY Burnaby	POSTAL CODE V5G 3B2		MANAGER Traci Skaalrud

INSPECTION DATE February 03, 2023	ADDITIONAL INSP. DATE (multi-day) January 25, 2023		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 5.5
ARRIVAL 11:15 AM	DEPARTURE 03:15 PM	ARRIVAL 02:00 PM	DEPARTURE 03:30 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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 · Hygiene and Communicable Disease Control · Physical Facility · Medication · Staffing · Nutrition and Food Services · Policies and Procedures · Program · Care and Supervision · 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 CCFL website at www.fraserhealth.ca/residentialcare for: · Additional resources, and · Links to the Legislation (CCALA and 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

STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person. Observation: 1 volunteer staff file reviewed had no criminal record check (CRC). The staff assisting with the inspection informed the LO that a this staff was of an age that did not require a CRC. Corrective Action(s): Please ensure that all employees including volunteers present in the facility to support the PICs must have a copy of current CRC on file prior to employment. Date to be Corrected: February 17, 2023 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: The following was observed: 1). The medication cart was left unlocked and unattended in the hallway during lunch medication administration time. 2). 2/4 PICs' inhaler space has white residues indicating insufficient cleaning of it. Corrective Action(s): Please ensure that all staff comply with MSAC policies and procedures. Date to be Corrected: February 17, 2023 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 (CORRECTED DURING INSPECTION): 1). The common tub/bath room door was found propped open with no staff or PIC using the room. The cupboard where the cleaning chemicals are stored in the same room was also unlocked. 2). The review of 1/6 staff files noted no copies of current CPR/First aid certificate. Corrective Action(s): Please ensure that staff implement all policies appropriately. Date to be Corrected: CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation. Observation: 2/6 PICs' wound care plan dressing change frequency was not followed by staff. Corrective Action(s): Please ensure that staff monitor the appropriate implementation of the care plans. Date to be Corrected: February 17, 2023

Comments

Licensing Officer would like to thank the staff for their assistance in completing this inspection. This report was reviewed and discussed with manager. A copy of this report was left at the facility. Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

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 Feb 17, 2023

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