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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-BYTNCW
FACILITY NAME
Mayfair (The)		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
TBIU-9L9MMF
FACILITY ADDRESS
33433 Marshall Rd		FACILITY PHONE
(604) 855-7217
CITY
Abbotsford		POSTAL CODE
V2S 1K8		MANAGER
Azita Babai
INSPECTION DATE
March 02, 2021		ADDITIONAL INSP. DATE (multi-day)
March 04, 2021		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
9.5
ARRIVAL
09:00 AM		DEPARTURE
12:00 PM		ARRIVAL
09:30 AM		DEPARTURE
04:00 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 w ww.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: 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 contingency medication records noted that staff were not appropriately maintaining the records twice a week. Evidence of missing signatures more than 4 times was found.

Correction: Please ensure that all staff comply with the MSAC policies and procedures.
Corrective Action(s):
Date to be Corrected:

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: 2 of 8 PICs did not have complete falls follow up post unwitnessed falls.
Corrective Action(s): Please ensure that falls policies are implemented by employees appropriately.
Date to be Corrected:

CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: 1 of 8 PICs file reviewed found the wound care follow up was not consistent with the care plan in place. A dressing change protocol received a week prior to this inspection was not in place.
Corrective Action(s): Please ensure that care of PICs is consistent with the care plan and appropriate follow up is completed in a timely manner.
Date to be Corrected:


Comments

The Licensing Officer (LO) would like to thank the former and current Director of Care and the staff for their time and assistance in completing this routine inspection. It was noted that facility has appropriate systems in place to monitor provision of care and audit processes. There were evidence of a number of audit processes completed and filed for the inspection along with all the required facility documents for review. Licensee has designated visitor screening and staff entrance screening at 2 main entrances ensuring appropriate IPC mitigating measures.

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/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Mar 12, 2021
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.