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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
FBES-CJ9UKP
FACILITY NAME
George Derby Centre		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
3203592
FACILITY ADDRESS
7550 Cumberland St		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Ava Turner
INSPECTION DATE
September 14, 2022		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.5
ARRIVAL
01:00 PM		DEPARTURE
03:30 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# OBSERVED IN CARE
Introduction

An unscheduled follow up inspection to the Routine Inspection, dated March 15, 17 and 18, 2022, was conducted. Areas of noncompliance identified at the Routine Inspection were reviewed for compliance.
Visit the CCFL website at www.fraserhealth.ca/residentialcare
For additional resources, and links to the Legislation (CCALA and RCR): http://www.gov.bc.ca/residentialcarefacility http://www.fraserhealth.ca/your_environment/ccfl

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: 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: Five of 5 narcotic count books were inspected found 20 missing second signature in total since June 1, 2022.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: September 28, 2022

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): Two of 5 medication rooms had contingency medications past its expiration date.
Corrective Action(s): Please ensure that medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Date to be Corrected: September 14, 2022
Comments

Thank you to all staff for their assistance and cooperation in the completion of this follow-up inspection.

The facility was able to provide evidence that health services were provided as order received. A plan to repair the countertops in clean and soiled utility rooms is in place as per discussion. However 2 repeat contraventions have been identified. Findings were discussed with the leadership when LO was on site and followed up with a phone call.

The report was written off-site and a copy of the report was provided via email.

Please provide a written response to Licensing by September 28, 2022.
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
Sep 28, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.