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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

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FACILITY NAME Crawford Manor ("B")		SERVICE TYPES 125 Substance Use	FACILITY LICENSE # LSEO-AFXQ7G
FACILITY ADDRESS 10010 128th St			FACILITY PHONE (604) 317-3319
CITY Surrey	POSTAL CODE V3T 2Y9		MANAGER Deb MacLean

INSPECTION DATE April 28, 2021	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 2
ARRIVAL 12:30 PM	DEPARTURE 02:30 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE

Introduction

Routine Inspection Report

An unscheduled routine inspection was conducted 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 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. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.

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: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: During inspection of the physical facility, it was noted in several bedrooms that the dresser's and side tables were heavily scratched and marked, primarily on the tops of the furniture.
Corrective Action(s): Pleae ensure that all furniture for use by persons in care are maintained in a good state of repair.
Date to be Corrected: June 29, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: During inspection of the physical facility, a large flat screen TV was not secured to the cabinet base. It was noted to easily rock back and forth.
Corrective Action(s): Please ensure that any furnishings that have the risk of tipping over are properly secured.
Date to be Corrected: May 6, 2021

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31550 - RCR s.29(1)(a) - A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including (a) a safe, secure place in which the person in care may store valuable property.
Observation: During inspection of the physical facility, it was noted in each person in care's bedroom that the furnishings equipped with a lock are not usable as keys are no longer available.
Corrective Action(s): Please ensure that each person in care has a safe and secure bedroom furnishing to store valuable property.
Date to be Corrected: June 29, 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: In review of a person in care's health care records, it was noted that a TB test was not completed within 30 days of admission.
Corrective Action(s): Please ensure that all persons admitted to the facility comply with the TB Control Program.
Date to be Corrected: May 31, 2021

MEDICATION: 36080 - RCR s.69(1)(b) - A licensee must ensure that a pharmacist (b) records all medications on the person in care's medication administration record.
Observation: In review of the Medication Administration Records (MAR) for persons in care, it was noted on a person's MAR that staff were handwriting all the medications. This handwritten MAR had been in use for all of April 2021.
Corrective Action(s): Please ensure that a Pharmacist records all medications on the person's medication administration record.
Date to be Corrected: May 13, 2021

Comments

This Licensing Officer would like to thank the Manager and staff for their assistance in completing this routine inspection.

Details discussed:
- A meeting with the Pharmacist is upcoming. Please ensure the following items are noted and reviewed during the Medication Safety and Advisory Committee Meeting (MSAC):
(1) Medication policies are reviewed,
(2) The orientation and training program regarding the administration of medications is reviewed,
(3) Medication errors, if applicable, are reviewed.

Please provide a written response to how the noted contraventions will be addressed by May 13, 2021.

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 May 13, 2021

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