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Avonlea Care Centre Ltd

1658 Blondeaux Crescent Kelowna BC V1Y 4J7 · Residential Care - Licensing

Official record from Interior Health →

Inspection summary

Avonlea Care Centre Ltd has been inspected 13 times by Interior Health Authority since March 11, 2015. The most recent inspection, on September 17, 2025, recorded 2 infractions.

None of the 13 inspections on record were free of infractions. No inspections are on record from the past 12 months. All recorded findings relate to upkeep, equipment or paperwork rather than direct health risks.

Recent inspections have recorded fewer infractions than earlier ones, so the record is improving.

What these findings mean

Health authorities word their findings differently, so we group them by what they mean for the people in care. Higher-risk findings are the ones that could directly make someone sick, and they matter more here because young children, older adults and people who are unwell are more vulnerable to infection.

  • Permits, records and postingLower risk

    Operating permits, required signage, written procedures and logs. These findings are administrative: the documentation was missing or out of date at the time of inspection.

    Recorded 51 times across 9 separate inspections, most recently on September 17, 2025. For example: 1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?

  • Equipment and utensilsLower risk

    Equipment has to be made of cleanable materials, kept in good repair and stored properly. These findings are mostly about upkeep, like a cracked surface or worn part. They are generally lower risk but show how well the place is maintained.

    Recorded 6 times across 5 separate inspections, most recently on September 17, 2025. For example: 1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?

  • Food safety training and certificationLower risk

    Many jurisdictions require a trained or certified person on site, such as a certified food handler. These findings mean the training record or the trained person was missing at the time. They do not by themselves mean anything was handled unsafely.

    Recorded 2 times across 2 separate inspections, most recently on January 12, 2016. For example: 22- Is personal privacy respected and records and personal information kept confidential?

  • Other findingsLower risk

    Findings that do not fit the categories above, such as follow-ups that confirm an earlier violation was corrected, or requirements specific to this type of facility.

    Recorded 36 times across 11 separate inspections, most recently on June 4, 2024. For example: 2 - Does the supervising pharmacist consult with employees respecting medication interactions and other problems related to medication?

About this data

These results come from Interior Health Authority, which inspects food premises and other public facilities in this area. We republish the authority's public disclosure data and refresh it regularly; the official record is the final word.

13 inspections

  1. Routine Inspection

    2 infractions

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Upon review and discussion with the Manager it was determined that fire drills have not been occurring as per the site policy and procedure. There have been no fire drills practiced since February 2025 and instead, alarm activation drills have been occurring. Failure to practice fire drills as per the policy and procedure increases risk as staff and persons in care may be unprepared to respond effectively and safely. Please submit a corrective action plan by October 03, 2025, detailing how fire drills will be completed to ensure the facility policy is followed.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Upon discussion with the Manger, it was determined that ceiling tract lifts are not inspected on a regular basis. The licensee does have a system to ensure the ceiling tract lifts are maintained; however, the lifts are not regularly inspected. Inspecting equipment regularly is important to ensure it is safe and reliable, minimizing risk to persons in care. Please submit a corrective action plan by October 03, 2025, detailing how ceiling tract lifts will be inspected on a regular basis.
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
  2. Routine Inspection

    3 infractions

    • R9.2 - Does the supervising pharmacist consult with employees respecting medication interactions and other problems related to medication?
      • Observation(s): The Licensee's system to ensure that a supervising pharmacist is appointed to consult with employees respecting medication interactions and other problems related to medication was found to be ineffective. During the inspection, it was noted that there has not been a MSAC meeting since 2022 and that the facility has not had a supervising pharmacist within this time.
      • R9.2A - Appoint a supervising pharmacist to consult with employees respecting medication interactions and other problems related to medication; 68( 2 )(c)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The Licensee's system to ensure the medication safety and advisory committee (MSAC) policy is being followed was found to be ineffective. The policy indicates that the MSAC reviews adverse drug reaction and medication incident/near miss reports, recommending changes to prevent or reduce the likelihood of recurrence. During the inspection, it was noted that there has not been a MSAC meeting since 2022 and in follow up conversations with the Manager, it was noted that the pharmacy had not received any medication incident reports that were sent in and therefore had not had a chance to review and/or recommend any changes that may have been required.
      • R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The Licensee's system to ensure that hygiene is maintained as pertaining to personal items was found to be ineffective. During the inspection, it was noted that two unlabeled toothbrushes and one unlabeled shower loofah were in a tub room that is shared by persons in care.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
  3. Routine Inspection

    3 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The Licensee's system to ensure restraint documentation is recorded at the time of monitoring was found to be ineffective. At the time of inspection, it was noted that no restraint documentation had been recorded for the day. It was also noted that restraint documentation wasn't completed for the previous evening for the same person in care.
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The Licensee's system to ensure that medications are stored appropriately is ineffective. During the inspection, it was noted that a medication which required refrigeration was being stored in a refrigerator with food and beverages in the kitchen. The medication safety advisory committee policy requires all refrigerated medications to be stored separately from food and beverages and in the medication room.
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The Licensee's system to ensure emergency exits are not obstructed was found to be ineffective. During the inspection, it was noted that two folding tables were propped up next to an emergency exit and partially in the way of the door opening. The manager corrected this immediately during the inspection.
      • R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
  4. Routine Inspection

    1 infraction

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Licensee submitted the facility's menu for review. It was noted that the Licensee did not have a system in place to ensure that all of the meals on the menu contained at least three food groups, and that the snacks posted on the menu contain at least two nutritious items. The Manager reported during the inspection that the menu is in the process of being re-developed.
      • R5.1C - Provide for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups described in Canada's Food Guide; 62( 2 )(a)
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
  5. Routine Inspection

    3 infractions

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): UNRESOLVED from inspection conducted on Oct 17, 2018 The employee faxed the Ministry of Justice the application form for a Criminal Record Check on October 25, 2018. As of February 2019 the Criminal Record Check had not yet been received; therefore the Manager contacted the Ministry of Justice to inquire on the status of the CRC, and was informed the employee had not made the payment required to complete the check. The manager spoke to the employee who stated that payment was submitted in March 2019. To date the Criminal Record Check has not been received by the Manager. The Manager stated the HR department was aware and was following up with the Ministry and the employee. However, there is no documented evidence to show the actions that HR has taken to date to follow up with the Ministry of Justice. Licensing requested a H&SP to be submitted to Licensing until an updated Criminal Record Check is received and reviewed by Licensing.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system in place to ensure abnormal findings of bath assessments are documented in persons in care's progress notes, the manager is notified, and a treatment sheet is started is ineffective. Licensing Officer (LO) reviewed a person in care's weekly bath assessment that was documented in the spa book and noted the abnormal findings from the assessment was not documented in the person's progress notes. The manager was not notified and a treatment sheet was not initiated. There was no documented follow up assessment indicating if the abnormal findings were progressing or resolved.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The system that is in place to ensure that persons in care's care plans are updated when there is a change in their condition is ineffective. LO reviewed documentation that a person had an open area, however it was not noted in their care plan, nor was there a plan of treatment.
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  6. Routine Inspection

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): There is no system in place to ensure that all employees have an up to date Criminal Record Check from the Ministry in place. Licensing Officer (LO) reviewed an employee's file and observed the criminal record check from the Ministry had expired. This employee does not work directly with persons in care, and is never in the facility alone with the persons in care. There is no system in place to ensure that the Employee responsible for the preparation and delivery of food receives ongoing education respecting the preparation and delivery of food, and nutrition.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • R3.1R - Ensure employees responsible for the preparation and delivery of food receive ongoing education respecting the preparation and delivery of food, nutrition, and if required, assisted eating techniques; 44 ( 1 )(b)
  7. Monitoring

    1 infraction

    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): November 14, 2017 - Employees did not follow a persons in care's medical care plan. The care plan stated to take and record vital signs, and document all actions taken during and following a medical event. LO reviewed the persons in care's progress notes and found that the vitals signs, and all of the actions that were taken during and following a recent medical event were not documented. The process that is in place for ensuring all persons in care's care plans are reviewed, and revised at least once a year is ineffective. A person in care's medical care plan has not been reviewed or revised within the last year.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  8. Monitoring

    10 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): June 15, 2017 - UNRESOLVED - The facility's system to ensure compliance with the reporting of reportable incidents immediately to Licensing is ineffective. LO reviewed the in-house incident reports and discovered a reportable incident that occurred Jan 01, 2017. This incident was not reported to Licensing.
      • R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): June 15, 2017 - The facility's system to ensure compliance for maintaining equipment in a clean condition that is used by multiple persons in care is ineffective LO observed three lifts in the hallway that are used by multiple persons in care. LO observed the lifts to not have been cleaned as the handles had unknown residue stuck on them, and the bottom of the lifts appeared to have spilled and dried liquid substance, and layers of dust and dirt. LO inquired about the cleaning system for the lifts and was told housekeeping was responsible for the cleaning of the lifts.
      • R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • RB1.9 - Are persons in care able to have family or a representative participate on the resident or family council on their own behalf?
      • Observation(s): June 15, 2017 - UNRESOLVED - The facility is not conducting family/resident council meetings.
      • RB1.9A - Ensure persons in care are able to have family or a representative participate on the resident or family council on their behalf.
    • RB1.10 - Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
      • Observation(s): June 15, 2017 - UNRESOLVED - The facility does not have a system in place to ensure compliance with offering persons in care and their representatives the opportunity to establish a council or come together yearly and meet with the Licensee.
    • RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
      • Observation(s): June 15, 2017 - The facility's policy does not guide the employees to create a falls plan to prevent falls and to follow up on falls for persons in care who are prone to falling.
      • RB1.23A - Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): June 15, 2017 - UNRESOLVED - The facility does not have a system in place to ensure compliance with the monitoring of the care and services they provide to the persons in care. LO reviewed persons in care 's nursing notes for post falls documentation. It was documented that the person in care was experiencing rib pain the day following the fall and the Director of Care (DOC) had been notified. There was no further documentation to indicate the person in care had been assessed, or that any follow up care was provided to them following the fall. An in-house incident report (IR) for a fall was reviewed by LO. The IR stated a person in care went to the hospital however, this incident was not reported to Licensing as per the facility's policy, and as the Residential Care Regulation requires. The facility does not have a system in place to monitor the food service they provide to persons in care.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): June 15, 2017 -The facility does not have a policy in place to ensure compliance with the Residential Care Regulation for complaint and dispute resolution. UNRESOLVED - The facility's policy and procedure for responding to expressed concerns and complaints does not guide the employees in complying with the Residential Care Regulation. The policy does not direct employees to keep a record of complaints or concerns brought forward, nor does it direct the employees to respond to complaints or concerns promptly. The facility does not have a system in place to review their policies to ensure the policies guide the employees in all matters related to care and supervision of persons in care. The facility's falls policy does not guide the employees in falls prevention or responding to a fall. The falls policy does not guide employees to develop a falls prevention care plan for persons in care who are prone to falling. The Residential Care Regulation requires the falls prevention care plan to address: 1) an assessment of the nature of the risk of falling presented by the person in care, 2) a plan for preventing the person in care from falling and, 3) a plan for following up on any falls suffered by a person in care. The facility does not have a system in place to ensure all policies are reviewed and revised at least yearly. The facility has reviewed some of their policies, however the majority of the policies have not been reviewed within the last year.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • R2.1V - Ensure there are written policies and procedures for how persons in care, their parents or representatives and contact persons may express concerns, make complaints and resolve disputes under section 60; 85( 2 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): June 15, 2017 - The facility does not have a system in place to ensure files for each person in care contains a photograph for identification. The facility has two persons in care who do not have a photograph on file. One person in care was admitted to the facility 7 months ago, and the second person in care is a new admission.
      • R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
    • R4.6 - Are facility records current and complete?
      • Observation(s): June 15, 2017 - UNRESOLVED -The facility does not have a system in place for the monitoring of food services provided to persons in care.
      • R4.6D - Retain the results of monitoring of food services and nutrition care; 87(c)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): June 15, 2017 - The facility does not have a system in place to monitor persons in care to ensure their needs continue to be met. LO observed nursing notes that identified a person in care was experiencing rib pain the day following a fall. There was no follow up assessment or documentation to indicate the person in care was assessed or that the pain had resolved. June 15, 2017 - The facility does not have a system in place to offer persons in care and their representatives the opportunity to establish a council or come together yearly and meet with the Licensee.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • R10.2S - Provide at least an annual opportunity for councils, or if no council is established, as a group, to meet with the licensee to promote the collective and individual interests of the persons in care and involve the persons in care in decision making on matters that affect their day to day living; 59(b)(i)(ii) (Show More)
  9. Monitoring

    8 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): December 30, 2016 -UNRESOLVED - The facility's system for ensuring compliance with having restraint care plans in place for persons in care who use restraints is ineffective. The facility is monitoring the person in care while the restraint is in use and there is written consent from the family and the doctor, however the facility does not have restraint care plans in place for the persons in care who use them.
      • R4.3A - Record the type or nature of the restraint used in the person's care plan; 84(a)
      • R4.3B - Record the reason for the use of restraint in the person's care plan; 84(b)
      • R4.3C - Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
      • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): December 30, 2016 - The facility does not have a system in place to ensure compliance with incident reporting. LO observed nursing notes that had documentation of three separate reportable incidents. When discussed with the manager/DOC it was found that all three incidents had not been reported to Licensing, the funder, or doctor as per the facility's incident reporting policy.
      • R4.5C - Immediately notify the medical or nurse practitioner responsible for the person in care involved in a reportable incident; 77( 2 )(b)
      • R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
      • R4.5E - Immediately notify the funding program, if any, if a person in care is involved in a reportable incident; 77( 2 )(d)
    • RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
      • Observation(s): December 30, 2016 - The facility does not have a system in place to ensure compliance with care plans taking into account the unique abilities, physical, and social needs of the persons in care. LO reviewed nursing notes that stated a person in care had independently left the facility in the am and had still not returned at 2300 . The person in care does not have a care plan in place that addresses his specific need and request to leave the facility independently. The facility does not have a system in place to ensure compliance with updating persons in care's care plans when they have a substantial change in their condition. LO reviewed progress notes and persons in care's care plans. LO found the care plans were not updated when persons in care had a substantial change in their condition. December 30, 2016 -UNRESOLVED - The facility's system for ensuring compliance with having restraint care plans in place for persons in care who use restraints is ineffective. The facility is monitoring the person in care while the restraint is in use and there is written consent from the family and the doctor, however the facility does not have restraint care plans in place.
      • RB1.23A - Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): December 30, 2016 - The facility's system to ensure compliance with the monitoring of the care and services provided to persons in care is ineffective. The facility did not report to Licensing three reportable incidents that occurred in December 2016. A person in care who was reported to have an open wound in November 2016 did not have documented wound care or follow up. The DOC stated she was unaware of the wound, however when she examined their skin on Dec 27, 2016 there were no open areas. Persons in care who use restraints do not have restraint care plans in place. A person in care who independently leaves the facility does not have a care plan in place to guide the employees should the person in care not let them know they are leaving or should they not return by the time indicated.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): December 30, 2016 - UNRESOLVED - The facility's system to ensure compliance with providing a policy and procedure to guide employees for the documentation and follow up of complaints is ineffective. The facility's complaint policy states if the employee becomes aware that a family or person in care has a complaint or concern a complaint record is not to be initiated and the documentation occurs only in the progress notes and communication book. The communication book is not kept as a record for complaints, therefore the facility does not have a record of documented concerns or complaints, nor do they have documentation of the facility's follow up to the complaints. The Facility does not have a system in place to ensure compliance with having written policies and procedures for the purpose of guiding employees in all matters related to care and supervision of persons in care. The facility does not have a wound care policy and procedure in place. LO reviewed nursing notes of persons in care and observed documentation from November 2016 of a person in care having an open wound. There was no documentation to indicate wound care had been provided, nor was there a documented nursing assessment, or any follow up documentation indicating that the wound was resolved. Upon discussion with the DOC she stated that she was unaware of that wound, however she had assessed the person in care's skin on December 27, 2016 and there were no open areas at that time. The Facility's system to ensure compliance with employees following the facility's policies and procedures is ineffective. LO observed nursing notes that documented three separate reportable incidents and when discussed with the manager/DOC they had not been reported to Licensing, the funder, or doctor as per facility policy and Residential Care Regulations .
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
      • R2.1V - Ensure there are written policies and procedures for how persons in care, their parents or representatives and contact persons may express concerns, make complaints and resolve disputes under section 60; 85( 2 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): December 30, 2016 - The facility's system for ensuring compliance with obtaining character references for all employees is ineffective. LO reviewed five employee files and found one file to be missing character references. The facility's system for ensuring compliance with obtaining evidence of employees complying with the Provinces immunization programs in ineffective. LO reviewed five employee files and found one file to be missing immunization screening.
      • R3.1C - Obtain character references for all employed persons; 37( 1 )(b)
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
    • R4.6 - Are facility records current and complete?
      • Observation(s): December 30, 2016 - The facility does not have a system place to ensure compliance with the monitoring of food service and nutrition care. In discussions with the manager/DOC it was revealed that the facility is not monitoring or auditing their food service and nutrition care. UNRESOLVED- The facility does not have a system in place for ensuring compliance with retaining a record of complaints made and the responses to them. The facility's complaint policy states if the employee becomes aware that a family or person in care has a complaint or concern a complaint record is not to be initiated and the documentation occurs only in the progress notes and communication book. The communication book is not kept as a record for complaints, therefore the facility does not have a record of documented concerns or complaints and the facility's follow up to them.
      • R4.6D - Retain the results of monitoring of food services and nutrition care; 87(c)
      • R4.6F - Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): December 30, 2016 - The facility does not have a system in place to ensure compliance with care plans taking into account the unique abilities, physical, and social needs of the persons in care. LO reviewed nursing notes that stated a person in care had independently left the facility in the am and had still not returned at 2300. The person in care does not have a care plan in place that addresses his specific need and request to leave the facility independently. The facility does not have a system in place to ensure compliance with updating persons in care's care plans when they have a substantial change in their condition. LO reviewed progress notes and persons in care's care plans. LO found the care plans were not updated when persons in care had a significant change in their condition.
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  10. Monitoring

    10 infractions

    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): June 01, 2016 - The facility's system for ensuring compliance with the documentation of reassessments of restraints is ineffective. LO reviewed restraint documentation in persons in care's chart and was unable to locate how often the restraint would be reassessed and any evidence of the reassessment.
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): June 01, 2016 - The facility's system to ensure furniture is in a clean condition and in a good state of repair is ineffective. LO observed the furniture in the living room to be noticeably dirty and the seams of a chair's cushion are coming apart.
      • Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
      • Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): June 01, 2016 - The facility's system to ensure compliance with self monitoring of the care and services it provides is ineffective. The facility does not currently have a process in place to monitor and update nutritional, oral and wound care plans. Care plans reviewed did not reflect the persons in care's current conditions.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 9 - Are persons in care able to have family or a representative participate on the resident or family council on their own behalf?
      • Observation(s): June 01, 2016 - UNRESOLVED - The facility's system to ensure compliance with resident/family council meetings is ineffective. The facility has not conducted or arranged a resident/family council meeting at the facility.
      • Ensure persons in care are able to have family or a representative participate on the resident or family council on their behalf.
    • 10 -Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
      • Observation(s): June 01, 2016 - UNRESOLVED - The facility's system to ensure compliance with resident/family council meetings is ineffective. The facility has not conducted or arranged a resident/family council meeting at the facility.
    • 23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
      • Observation(s): June 01, 2016 - The facility's system to ensure compliance with care plans reflecting persons in care's needs is ineffective. LO reviewed person in care's charts and care plans and found persons in care with skin breakdown did not have a care plan in place to guide staff.
      • Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): June 01, 2016 - The facility's complaint resolution policy is ineffective. The policy indicates that if an employee becomes aware of a family/person in care's concern no complaint record is to be initiated, and the documentation occurs only in the progress notes and communication book. Therefore there is no record of concerns or complaints that are a severity of level 1 or 2 that have been brought forward.
      • Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(a)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): June 01, 2016 - UNRESOLVED -The facility's system to ensure compliance with obtaining written consent to call an ambulance or doctor is ineffective. LO reviewed persons in care's charts and was unable to locate signed consents. June 01, 2016 - UNRESOLVED - The facility's system to ensure compliance with the documentation of persons in care's monthly weights in their charts is ineffective. The manager reports the monthly weights are taken however LO reviewed 5 persons in care's charts and 3 of the charts were missing consistent documentation of monthly weights.
      • Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): June 01, 2016 - UNRESOLVED - The facility's system to ensure compliance with resident/family council meetings is ineffective. The facility has not conducted or arranged a resident/family council meeting at the facility.
      • Provide at least an annual opportunity for persons in care and their parents or representatives, family members and contact persons to establish councils or similar organizations to represent the interests of persons in care; 59(a)
      • Provide at least an annual opportunity for councils, or if no council is established, as a group, to meet with the licensee to promote the collective and individual interests of the persons in care and involve the persons in care in decision making on matters that affect their day to day living; 59(b)(i)(ii) (Show More)
    • 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): June 01, 2016 - UNRESOLVED - The facility's system to ensure compliance with oral care plans is ineffective. Oral care plans reviewed have not been updated in over a year. The oral care plans do not reflect the Persons in Care who have had changes in their dental conditions. The facility's system to ensure compliance with nutritional care plans is ineffective. The nutritional care plans reviewed have not been updated in over a year. There were two persons in care who had swallowing assessments in their charts and their nutritional care plans did not reflect the changes required to be made. The facility's system to ensure compliance with care plans reflecting persons in care's needs is ineffective. LO reviewed person in care's charts and care plans and found persons in care with skin breakdown did not have a care plan in place to guide staff.
      • Care plans must includes an oral health care plan; 81( 3 )(b)
      • Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)
      • Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
      • Develop a nutrition plan for each person in care and review the plan on a regular basis (Applies to a facility with 24 or fewer persons in care); 83( 1 )(a)( 3 )(a)
      • Ensure reasonable steps are taken when a nutritional plan is developed without the assistance of a dietician to assess specific nutritional needs including considering whether the person is at risk of being inadequately nourished because of a physical or mental condition, a history of issues that affect eating or any other relevant factor; 83( 1 )(b)(i)(ii)(iii) (Show More)
  11. Monitoring

    18 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Jan 11, 2016 - UNRESOLVED - Unable to locate written consent from the doctor and resident/family/representative for restraints. -Unable to locate the reassessment documentation for continuous restraints.
      • A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
      • Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73( 2 ); 75( 2 )(a)(i)(ii)(b)
    • 3.2 Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): Jan 11, 2016- Unable to locate documentation supporting a doctors order for specimen collection was completed and taken to lab.
      • There must be sufficient numbers of trained and experienced employees on duty at all times. Staffing patterns must meet the needs of persons in care and assist persons in care with activities of daily living, including eating, mobility, dressing, grooming and hygiene in a manner consistent with the health, safety and dignity of persons in care; 42( 1 )(a)(b) (Show More)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): Jan 11, 2016 - UNRESOLVED - Unable to locate restraint care plans for resident's who use restraints.
      • Record the type or nature of the restraint used in the person's care plan; 84(a)
      • Record the reason for the use of restraint in the person's care plan; 84(b)
      • Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): Jan 11, 2016 - LO unable to locate completed in house and Licensing reports for incidents that occurred in 2015.
      • Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(a)
      • Retain a record of reportable incidents involving persons in care; 88(c)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Jan 11, 2016 - The facility did not have a list of the employees who received influenza immunization. Nor does the facility have a plan in place to monitor the employees compliance for those who did not receive the influenza immunization.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Jan 11, 2016 - UNRESOLVED - The facility is not screening residents for the pneumococcal vaccinations, nor do they provide information to the residents and their families regarding the benefits of it.
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
      • Provide information to persons in care regarding the benefits of immunization including pneumococcal, annual influenza and tetanus-diphtheria if appropriate; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): Jan 11, 2016 - There are residents who are at risk of falls and there are no falls prevention plans in place for these residents. -Unable to locate restraint care plans for residents who use restraints
      • Ensure all alternatives to the use of a restraint have been considered and either implemented or rejected; 73( 2 )(a)
      • Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
      • Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
      • Provide in the care plan a plan to address, if there is agreement to the use of restraints, the type or nature of restraint and the frequency of reassessment; 81( 3 )(a)(iii)
      • Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (Show More)
    • 9 - Are persons in care able to have family or a representative participate on the resident or family council on their own behalf?
      • Observation(s): Jan 11, 2015 - There is no resident or family council in place
      • Ensure persons in care are able to have family or a representative participate on the resident or family council on their behalf.
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Respect personal privacy and keep records and personal information confidential.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Jan 11, 2016 - The managers name is not prominently displayed at the facility.
      • Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Jan 11, 2016 - UNRESOLVED - The restraint policy is inadequate as it does not guide the staff in meeting the RCR in regards to restraints. -The facility is not following their policy for performance appraisals, as they are more than 1 year overdue. -Policies have not been reviewed or updated in the past year. -The emergency plan was not updated with current contact names and phone numbers
      • Update emergency plans if there is any change in the facility; 51 ( 2 )
      • Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Jan 11. 2016 - UNRESOLVED - Documentation is missing in resident's progress notes indicating Doctors orders had been followed. -UNRESOLVED- Employee appraisals are over due from April 2014.
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
      • Designate an employee qualified by training and experience to supervise employees who provide care to persons in care, coordinate and monitor the care of persons in care and manage unusual situations or emergencies; 41( 2 )(a)(b)( c)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Jan 11, 2016 - Unable to locate signed consent to call a doctor or ambulance in case of an emergency. -Unable to locate a care plan for a resident. -Resident's weights have not been documented in their charts since Sept 2015. -Resident 's charts and the MAR is stored in a room off the dining room where the door is propped open at all times.
      • Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
      • Ensure a care plan is developed within 30 days for persons in care admitted for more than 30 days; 81.1; Director of Licensing Standards of Practice: Advance Directives and Care Plans
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
      • Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • 4.6 Are facility records current and complete?
      • Observation(s): Jan 11, 2016- UNRESOLVED - The resident's charts are stored in an area where the door is left unlocked and open when there is no staff present in the room, this leaves resident's records accessible to residents and visitors.
      • Ensure records related to a person in care are accessible only to employees who require access to perform their duties in relation to the person; 91 ( 3 )
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Jan 11, 2016 - There was no signage posted in the entrance of the facility notifying visitors of flu season. The hand sanitizer and masks were stored on the second shelf of a table and not in a clear visible area.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Jan 11, 2015 - UNRESOLVED - Many doors and door frames of Resident's bedrooms are heavily damaged and require painting.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Jan 11, 2016 - The residents who leave the facility temporarily do not carry facility ID. -The facility has not conducted a resident/family council meeting.
      • Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56( 1 ) ( 2 )
      • Provide at least an annual opportunity for persons in care and their parents or representatives, family members and contact persons to establish councils or similar organizations to represent the interests of persons in care; 59(a)
      • Provide at least an annual opportunity for councils, or if no council is established, as a group, to meet with the licensee to promote the collective and individual interests of the persons in care and involve the persons in care in decision making on matters that affect their day to day living; 59(b)(i)(ii) (Show More)
    • 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Jan 11, 2015 -UNRESOLVED - Oral care plans are not resident specific and they lack detailed information of the resident's oral care needs and dentist/hygienist visits. -Oral care plans are not reviewed regularly to ensure new pertinent information is added. -Resident charts have nutritional assessments however there are no nutritional care plans in place. -There are recreational assessments however there are no recreational care plans in place.
      • Care plans must includes an oral health care plan; 81( 3 )(b)
      • Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)
      • Care plans must include a recreation and leisure plan; 81( 3 )(d)
      • Develop a nutrition plan for each person in care and review the plan on a regular basis (Applies to a facility with 24 or fewer persons in care); 83( 1 )(a)( 3 )(a)
      • Ensure reasonable steps are taken when a nutritional plan is developed without the assistance of a dietician to assess specific nutritional needs including considering whether the person is at risk of being inadequately nourished because of a physical or mental condition, a history of issues that affect eating or any other relevant factor; 83( 1 )(b)(i)(ii)(iii) (Show More)
  12. Monitoring

    21 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Sept 14, 2015 - UNRESOLVED from March 11, 2015- Unable to locate written consent from the doctor and family/representative for restraints. -Unable to locate reassessment of restraints. -The restraint policy does not include that written consent is required by family/representative.
      • A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
      • Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73( 2 ); 75( 2 )(a)(i)(ii)(b)
      • Ensure there are written policies and procedures regarding the use of restraints in an emergency; 85( 2 ) (i)
    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Sept 14, 2015 - The MAR is missing initials for routine medications that are administered.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): Sept 14, 2015 - UNRESOLVED from March 11, 2015 - Unable to locate restraint care plans for Resident's who use restraints.
      • Record the type or nature of the restraint used in the person's care plan; 84(a)
      • Record the reason for the use of restraint in the person's care plan; 84(b)
      • Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
      • Keep a record of employee compliance with the requirements of Division 5 (Use of Restraints) of Part 5 in the persons care plan; 84 (f)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Sept 14, 2015 - Unable to locate a TB screen in an employees's file.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Sept 14, 2015 - The facility is not screening the residents for the pneumococcal vaccination, nor do they provide information to the residents and their families regarding the benefits of it.
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
      • Provide information to persons in care regarding the benefits of immunization including pneumococcal, annual influenza and tetanus-diphtheria if appropriate; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 8.2 Does the program of activities support individualized care plan requirements?
      • Observation(s): Sept 14, 2015 - UNRESOLVED from March 11, 2015 - The assistant manager states the staff are doing in house programming however there is no activity calendar posted for the in house activities.
      • Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55( 1 )(a)(ii)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): Sept 14, 2015 - UNRESOLVED from March 11, 2015 - Unable to locate written consent from doctor and family, care plans, and ongoing monitoring of restraints for residents who use restraints. -Unable to locate a falls care plan for a resident who is a high falls risk.
      • Ensure a restraint is not used unless it is as minimal as possible, taking into consideration both the nature of the restraint and the duration for which it is used; 73( 1 )(b)
      • Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
      • Ensure all alternatives to the use of a restraint have been considered and either implemented or rejected; 73( 2 )(a)
      • Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
      • Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
      • Provide in the care plan a plan to address, if there is agreement to the use of restraints, the type or nature of restraint and the frequency of reassessment; 81( 3 )(a)(iii)
      • Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (Show More)
    • 13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
    • 14 - Are sufficient materials, supplies and equipment for the program of activities readily accessible, safe, and provided without charge?
    • 17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
      • Post the most recent routine inspection in a prominent place.
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Respect personal privacy and keep records and personal information confidential.
    • 23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
      • Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): September 14, 2015 - Both the licence and the last inspection report are not displayed in a prominent area.
      • Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
      • Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Sept 14, 2015 - UNRESOLVED from March 11, 2015 - The restraint policy is inadequate as it does not guide the staff in meeting the RCR in regards to restraints. -The staff are not following the facility's least restraint policy. -The facility is not following their policy on orientating staff to the facility policies. -The facility is not following their policy for performance appraisals, some are over a year overdue.
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Sept 14, 2015 - UNRESOLVED from August 27, 2014 - A staff file was found to be missing two character references. Sept 14, 2015 - UNRESOLVED from August 27, 2014 - Some performance appraisals have not been conducted in over a year. Sept 14, 2015 - A variety of employee file's were reviewed and found to be missing a TB Screen, a Nursing Certificate or license /registration number, and work history.
      • Obtain character references for all employed persons; 37( 1 )(b)
      • Obtain a record of work history for all employed persons; 37( 1 )(c)
      • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37( 1 )(d)
      • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Sept 14, 2015 - The MAR is left on top of the medication cart that is stored in the hallway and accessible to all residents, and visitors. -The resident's charts are stored in a staff area where the door is left unlocked and open when no one is in the room, leaving resident's records accessible to residents and visitors.
      • Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): Sept 14, 2015 -UNRESOLVED from March 11, 2015 - Unable to locate character references, TB screens, and up to date performance appraisals in the employee's files.
      • Keep employee character references; 86(b)
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 4.6 Are facility records current and complete?
      • Observation(s): Sept 14, 2015 - The resident's charts are stored in an area where the door is left unlocked and open when there is no staff present in the room, this leaves resident's records accessible to residents and visitors.
      • Ensure records related to a person in care are accessible only to employees who require access to perform their duties in relation to the person; 91 ( 3 )
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Sept 14, 2015 - The fridge temperature had not been recorded in the last 6 days.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Sept 14, 2015 - The medication cart is stored in a common area and not in a locked room. -The emergency monitoring checklist was not completed in August and has not yet been completed for September.
      • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
      • Ensure all medications are safely and securely stored; 69( 3 )(a)
    • 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Sept 14, 2015 - A care plan was inspected by LO that has not been updated within the last year. -Unable to locate a wound care plan for a resident with ongoing wounds. -Nutritional care plans were not updated for residents that had changes made to their diets following assessments from a speech therapist.
      • Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
      • Review the nutrition plan with a dietician, if requested or required by the health care provider, licensing, or funding program; 83( 3 )(c)(i)(ii)(iii)
  13. Monitoring

    14 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): March 11, 2015 - Unable to locate written consent from the doctor and family/representative for restraints. -Unable to locate the reassessment documentation for continuous restraints.
      • Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73(2); 75(2)(a)(i)(ii)(b)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): March 11, 2015 - Unable to locate restraint care plans for Resident's who use restraints.
      • Record the type or nature of the restraint used in the person's care plan; 4(a)
      • Record the reason for the use of restraint in the person's care plan; 84(b)
      • Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
      • Keep a record of employee compliance with the requirements of Division 5 (Use of Restraints) of Part 5 in the persons care plan; 84 (f)
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): March 11, 2015 --A bedside table in a Resident's room is damaged and missing drawer handles.
      • Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • 8.1 Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): March 11, 2015 - The facility is in the process of setting up an in house recreation program. The calendar is up and the DOC is working on a resource binder for in house activities.
      • Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55(1)(a)(i)
    • 8.2 Does the program of activities support individualized care plan requirements?
      • Observation(s): March 11, 2015- A recreation program is currently being developed. Individual recreation assessments and recreation care plans are in the process of being completed.
      • Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55(1)(a)(ii)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Ensure a restraint is not used unless necessary to protect the person in care or others from serious physical harm; 73 (1)(a)
      • Ensure a restraint is not used unless it is as minimal as possible, taking into consideration both the nature of the restraint and the duration for which it is used; 73(1)(b)
      • Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73(1)(c)
      • Ensure all alternatives to the use of a restraint have been considered and either implemented or rejected; 73(2)(a)
      • Train employees in alternatives to the use of restraints. They must be able to determine when alternatives are most appropriate, when to use restraints and how to monitor the use of them; 73(2)(b)(i)
      • Employees administering a restraint must follow any instructions in the care plan of the person in care respecting the use of restraints; 73(2)(b)(ii)
      • Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73(2)c
      • Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75(3)(a)(i)(ii)(b) (Show More)
      • Provide in the care plan a plan to address, if there is agreement to the use of restraints, the type or nature of restraint and the frequency of reassessment; 81(3)(a)(iii)
    • 13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): March 11, 2015 - The facility is in the process of resolving this.
    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): March 11, 2015 - The restraint policy is inadequate as it does not guide the staff in meeting the RCR in regards to restraints. -The staff are not following the facility's least restraint policy. -The facility is not following their policy on performance appraisals, ass they are more than 1 year overdue.
      • Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85(1)(a)
      • Ensure policies are implemented by employees; 85(1)(d)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): August 27, 2014 - UNRESOLVED - Staff files were found to be missing at least two character references. August 27, 2014 - UNRESOLVED- Performance appraisals have not been conducted in over a year. March 11, 2015 - Documentation is missing in Resident's progress notes for interventions or follow up after a resident expressed concerns.
      • Obtain character references for all employed persons; 37(1)(b)
      • Ensure that employed persons have the training and experience and demonstrate the skills to carry out duties assigned to the manager or employee; 37(2)(c)
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40(1)(a)(b)
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): March 11, 2015 - Unable to locate character references and up to date performance appraisals in the employee's files.
      • Keep employee character references; 86(b)
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): March 11, 2015 - There was food located in both refrigerators that was not dated. This was resolved during the inspection.
      • Ensure that food is safely prepared, stored, served and handled; 63 (1)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): March 11, 2015 - Doors and door frames of Resident's bedrooms are heavily damaged.
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): March 11, 2015 - There was documentation in Resident's progress notes that indicated follow was required. LO unable to locate follow-up documentation.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 (1)
      • Ensure a caregiver documents the facts concerning the person's inability to write in facility records and in the file of the person in care. A notation describing how agreement to the use of restraints was discussed with, and obtained from, the person in care should also be made on the consent form used by the facility; Director of Licensing Standards of Practice: Agreement in Writing to the Use of Restraints, The Adult Guardianship Act section 3 (Show More)
    • 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): March 11, 2015 - Oral care plans are not resident specific and they lack detailed information of the Resident's oral care and dentist/hygienist visits. -There are currently no recreation care plans in place for the Residents. -Care plans are not being monitored regularly to ensure up to date information of Resident's condition is current. -Following a dental appointment the Resident's oral care plan did not reflect the outcome of the visit and the care required following the appointment.
      • Care plans must includes an oral health care plan; 81(3)(b)
      • Care plans must include a recreation and leisure plan; 81(3)(d)
      • Each care plan must be monitored on a regular basis to ensure proper implementation; 81(4)(a)
      • Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81(4)(b)(i)(ii)

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