Columbia Garden Care Village

800 10 Ave Invermere BC V0A 1K0 · Residential Care - Licensing

18 inspections

1. Routine InspectionApr 9, 2026

   4 infractions

   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): R1.1W - Based on a review of documentation, it is noted that the current system in place to ensure monitoring and compliance is ineffective. Specifically: - Monitoring of the recreation fridge temperature is not completed for the entirety of March or to date in April, with no documented evidence of follow‑up. - There is no evidence of ongoing monitoring or oversight of dietary plans located in the unit kitchen evidenced by multiple care plans not including a current picture, and one care plan dated 2024. - There is no evidence of oversight or monitoring of kitchen audits or related records, including substitution lists. - There is no evidence of monitoring of managed risk agreements to ensure all aspects of care are captured and reflected within the care plan. - There is no evidence of ongoing follow up of current audit results. Inconsistent monitoring and oversight increases the risk that community care services are not delivered consistently, safely, or in accordance with licensing requirements. Without regular monitoring, deficiencies may go undetected, required standards of care may not be maintained, and corrective actions may not be taken in a timely manner, potentially placing individuals at risk of harm and resulting in non‑compliance with the Community Care and Assisted Living Act and associated regulations. Submit by April 23, 2026, a written plan outlining how the contravention related to ensuring the care and services provided is regularly monitored has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 61 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
     • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
   • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
     • Observation(s): R5.1D - The current menu does not include, for each day, at least two nutritious snacks containing a minimum of two food groups, as outlined in Canada’s Food Guide. R5.1I - The documented substitution list shows that substitutions are not consistently aligned with the same food group or comparable nutritional value. The absence of menus that meet nutritional standards increases the risk that individuals do not receive adequate nutrition to support their health and well‑being. Without proper menu planning and oversight, dietary needs may not be consistently met, which may impact overall health outcomes and result in non‑compliance with Community Care Licensing requirements. Submit by April 23, 2026, a written plan outlining how the contravention related to ensuring the snack menu and substitution requirements has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 62(2)(b) and Section 62(2)(d) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
     • 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)
     • R5.1I - Provide substitutions from the same food group and have a similar nutritional value; 62( 2 )(d)
   • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
     • Observation(s): R10.2A - A review of care plans identifies that there is no system in place to ensure ongoing monitoring during mealtimes of persons in care who have approval to eat meals in their rooms. In addition, there is no documented evidence of current assessments confirming that persons in care who independently access the community are safe and capable and that their needs are adequately met. The absence of systems for ongoing monitoring and current assessment increases the risk that changes in a person’s abilities, safety, or care needs are not identified in a timely manner. This may result in unmet needs, increased risk of harm, and the potential for individuals to receive care that does not align with their assessed abilities or licensing requirements. Submit by April 23, 2026, a written plan outlining how the contravention related to monitoring the health and safety of each person in care to determine if their needs continue to be met has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 50(1) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
     • 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): RCR 81(2)(b) - A review of a care plan identifies that it does not include a plan for a person in care who is currently accessing the community independently. The absence of documented care planning for independent community access increases the risk that a person in care’s abilities, safety needs, and required supports are not adequately identified or addressed. Without clear planning and oversight, there is potential for unmet needs, increased risk of harm, and care delivery that does not align with assessed capabilities or licensing requirements. Submit by April 23, 2026, a written plan outlining how the contravention related to ensure care plans take into account the unique abilities, physical, social and emotional needs and preferences of persons in care has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 81(2)(b) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward. RCR 81(3)(a)(ii) - During a review of care plans, person in care records, and through discussion with the Director of Clinical Care, it is identified that a person in care who requires a behavioural care plan does not have all aspects of their current plan accurately captured in the care plan. The care plan does not fully reflect the interventions and supports currently implemented by the licensee. Complete documentation of all aspects of care is required to ensure staff have accurate and current information to appropriately guide care and support each person in care’s ongoing health, safety, and dignity. The absence of complete and current documentation in care plans increases the risk that staff do not have clear direction to consistently implement required behavioural supports. This may result in inconsistent care practices, unmet needs, increased safety risks for persons in care and others, and care delivery that does not align with assessed needs or Community Care Licensing requirements. Submit by April 23, 2026, a written plan outlining how the contravention related to care plans including a plan to address behavioural interventions has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 81(3)(a)(ii) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
     • 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)
     • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
2. Routine InspectionSep 18, 2025

   4 infractions

   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): R1.1W - A review of the compliance plan submitted in response to the January 2025 inspection did not include evidence of implementation or ongoing monitoring for the portion of the plan developed to achieve compliance with Residential Care Regulation (RCR) 61. A review of behavioural care plans and progress notes indicated that the previously submitted plan to address RCR 81(3)(a)(ii) was implemented and monitored. The absence of evidence of implementation and ongoing monitoring increases the risk that persons in care may not consistently receive the care and services outlined in the plan, which could impact their health, safety, and dignity. This is an ongoing contravention from the January 2025 inspection, and re-occurring from the October 2023 inspection. Submit by October 8, 2025, a written plan outlining how the contravention related to ensuring self monitoring of the facility has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 61 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
     • 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): R2.1S - A review of person in care records identified that one individual did not have a complete care plan developed within 21 days of admission, as required by the licensee's policy. Failure to follow the licensee's policy regarding timely development of care plans creates a risk that care needs may not be identified, communicated, or met, which could compromise the health, safety, and dignity of persons in care. Submit by October 8, 2025, a written plan outlining how the contravention related to ensuring policies are implemented by employees has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 85(1)(d) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): R4.1S - A review of a recent admission's temporary care plan identified that the short term care plan did not include all elements required under legislation. Incomplete documentation creates a risk that the person in care's needs may not be fully identified or consistently met, potentially impacting their health, safety, and dignity. Submit by October 8, 2025, a written plan outlining how the contravention related to ensuring that short term care plans include anything that must be recorded in a care plan has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 80 (2) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
     • R4.1S - Ensure a short term care plan developed on admission includes anything that must be recorded in a care plan; 80 ( 2 )
   • 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): R10.3M - A review of wound care plans identified that one plan did not include clear directions for treatment, a date of onset, or a nurse signature. Without this required information documented on the wound care plan, the licensee is unable to confirm whether the care being provided aligns with the terms and conditions of the care plan. Without complete documentation, there is a risk that the person in care may not receive treatment consistent with their care plan, which could negatively impact the healing of wounds and overall heath outcomes. Submit by October 8, 2025, a written plan outlining how the contravention related to ensuring that the care and supervision of a person in care is consistent with the terms and conditions of their care plan has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 82 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
     • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
3. Routine InspectionJan 7, 2025

   2 infractions

   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): The licensee continues to improve internal audit systems to monitor both the physical environment and the care and services provided. Multiple audits were evidenced as being completed during the inspection. A previously submitted compliance plan did not contain any evidence of implementation or ongoing monitoring of the plan. The system to ensure that all submitted plans are implemented, and contain evidence of both implementation and ongoing monitoring is ineffective.
     • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
   • 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 to ensure care plans include a plan to address applicable behavioral interventions was ineffective. During a review of person in care's records, which included progress notes, assessments, care plans, and behavioral care plans, it was identified that a person in care had ongoing identified behaviors that were not included on the current behavioral care plan.
     • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
4. Routine Inspection Follow-upAug 28, 2024

   1 infraction

   • R4.5 - Are incidents and notifications reported and records retained as required?
     • Observation(s): During follow up of a reportable incident it was identified that the incident was not immediately reported to Licensing as per legislative requirements; it was also identified that the representative/contact person, and the medical practitioner were not immediately notified of the person in care being involved in a reportable incident.
     • R4.5B - Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77( 2 )(a)
     • 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)
5. Routine InspectionApr 4, 2024

   2 infractions

   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): The system to ensure individuals employed as volunteers have a current criminal record check is ineffective. During a review of volunteer records it was identified that some volunteers did not contain a criminal record check on file, and some criminal record checks were noted to be outdated.
     • R3.1J - An individual may be employed as a volunteer who does not provide care or supervise persons in care if the manager/licensee has met with the person and obtained a criminal record check for the person; 37( 3 )(a)
   • 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 to ensure care plans of persons in care who smoke takes into account the unique abilities, needs, and preferences of the person in care is ineffective.
     • 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)
6. Routine InspectionOct 3, 2023

   4 infractions

   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): The system to regularly monitor the physical environment and care services provided are ineffective. Licensing acknowledges an increase in self-monitoring practices related to the care and services of persons in care; however, monitoring of systems, including corrective actions was noted to be inconsistent.
     • 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): It was identified during the inspection that the system to ensure policies are implemented by employees is ineffective. The policy related to completion of varying safety drills, including Code White drills was noted to have not been implemented by staff.
     • 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): The system to ensure water accessible to persons in care does not exceed 49 degrees Celsius is ineffective. The Licensee adjusted water temperature, and provided Licensing a plan for ongoing monitoring.
     • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
   • 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 to ensure all care plans are reviewed and modified following a substantial change in circumstances of the person in care is ineffective. During a random care plan review it was noted that multiple care plans contained information that was no longer relevant to the person in care.
     • 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)
7. Routine InspectionApr 12, 2023

   3 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): Of the charts reviewed it was identified that the system to ensure all documentation policies are implemented by staff is ineffective. This was evidenced by incomplete skin observation monitoring tools.
     • 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): Multiple bottes of chemical cleaners were noted to be accessible to persons in care in an unlocked cupboard under a sink in a common dining area. This contravention was corrected during the inspection. During a random inspection of person in care's rooms, hazardous material in the form of a sharp was identified in one room that was not secure. This sharp was noted to be accessible to persons in care as it was not secured, and the door to the room was also open.
     • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
   • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
     • Observation(s): The licensee does not currently have a system in place to ensure persons in care who smoke have been assessed for safety, have a plan in place, or a system to monitor ongoing health and safety. The system to approve, and reassess ongoing tray service is ineffective. In review of person in care's records there was no documented evidence of approval or reassessment for ongoing tray service as required.
     • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
     • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
8. Substantiated complaintFeb 1, 2023

   3 infractions

   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): The system to self-monitor the physical environment and care services provided to persons in care is ineffective as evidenced by the substantiated contraventions noted within this report. This is a re-occurring contravention from the previous inspections in July 2021 and July 2022.
     • 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): The Licensee identified that staff had not followed policies related to charting or following internet downtime procedures; therefore, the allegation is Substantiated.
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): The Licensee identified that employees did not comply with the policies and procedures of the medication safety and advisory committee; therefore, the allegation is Substantiated.
     • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
9. Routine InspectionJul 20, 2022

   5 infractions

   • R10.4 - Are restraint and fall prevention plans appropriate?
     • Observation(s): During the inspection it was identified that a person in care had a locking seatbelt on. It was noted that staff had implemented the restraint without proper assessment, trials, or consents. This restraint was removed during the inspection.
     • R10.4E - 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)
   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): It was identified during the inspection that the licensee does not have fully established self monitoring systems for monitoring the care and services provided.
     • 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): It was identified during the inspection that the system for ensuring that, the policy related to the orientation of new staff to the regulations, and the Act is being implemented, was ineffective. It was identified that the orientation process is currently not being implemented, and as a result there are gaps in staff knowledge.
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): It was noted during the inspection that performance evaluations are overdue. The licensee has self identified that staff require additional training, and Director of Clinical Care is exploring training/in-service options for staff.
     • R3.1K - 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)
   • 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): During the inspection it was noted that a care plan did not indicate the most recent date reviewed; a care indicated a person in care was a known elopement risk, however, licensee identified that this information is no longer accurate. The system to ensure care plans are reviewed, and/or modified to ensure it continues to meet the needs, preferences and is compatible with the abilities of the person in care was ineffective.
     • 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. Substantiated complaintDec 31, 2021

    2 infractions

    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Licensee identified that person in care prefers to wake naturally. While documentation noted that the person in care did receive morning care on the date in question, it was unclear of the time that care was provided. Licensee was unable to provide evidence of regular checks to show that the person in care was regularly monitored to ensure their needs continued to be met, therefore, the allegation is Substantiated.
      • 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 care plan was noted to have been updated following changes in the circumstances of the person in care; however, it did not include the preferences of the person in care related to waking, therefore, the allegation is Substantiated.
      • 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)
11. Routine InspectionJul 13, 2021

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): It was noted during the inspection that the system for ensuring the name of the current manager is posted appears ineffective. The previous managers name was noted on the complaints process signage that was posted at entrance. This contravention was corrected during inspection. The system for self monitoring appears to be ineffective. It was noted during the inspection that the system for ensuring nutrition care plans are updated in all locations was ineffective. Nutrition care plans were noted to be up to date on the online Care Organizer system; however, were noted to be outdated in the nutrition care plan binder that is accessed by staff daily.
      • R1.1N - 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)
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It was noted during the inspection that an under sink cupboard containing various cleaning products was unlocked, and accessible to persons in care. This contravention was corrected during inspection.
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 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): In an audit of multiple care plans, it was noted that the detailed interventions were inconsistently updated/reviewed. Multiple detailed intervention sheets were unclear as to the most up to date plan, as evidenced by no resolution, end or review date being documented.
      • 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)
12. MonitoringMay 1, 2018

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): While reviewing the facility complaint documentation, one reportable incident was observed in the documentation which was not reported to Licensing, inform Licensing on how the facility incident reporting procedures will be reviewed/updated to ensure all reportable incidents are submitted to Licensing in a timely manner.
      • 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)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Several restraint care plans were reviewed during this inspection, the plans included the type of restraint and were signed by the PIC's physician and representative, these plans are updated annually or as needed; the plans did not include how often the restraint needs to be monitored by care staff and how/where this is to be charted. Review restraint procedures/documentation to ensure they include monitoring procedures and charting requirements. Include in your response how the restraint charting is audited to ensure it is being completed.
      • R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): A PIC who has been assessed by the facility as an elopement risk did not have ID at the time of this inspection, Ensure every PIC who has been assessed as an elopement risk has some type of ID indicating their name, the facility name and emergency contact information at all times. Include in your response what type of ID procedure the facility will put in place, also include the system of auditing to ensure those PIC's who have been assessed as a wandering risk, have their ID.
      • R10.2M - Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56( 3 )(a)(b) (Show More)
    • 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): Several oral care plans reviewed during this inspection did not include specific information regarding the daily oral care needs for the PIC. Include in your response what systems will be put in place to ensure appropriate oral care plans are in place for every PIC, also include how this will be audited to ensure compliance.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
13. MonitoringJul 13, 2017

    2 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The system for recording resident immunization status appears to be ineffective. LO noted that residents do not have an immunization status on record beyond influenza.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • 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): In review of the MSAC pharmacy policies in the medication room, LO noted that the policy manual was last reviewed/revised in 2014.
      • R2.1N - Establish and review policies and procedures on safe and effective storage, handling and administration of medications; 68( 3 )(b)(i)
14. MonitoringMar 8, 2017

    7 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing observed ongoing non compliance in 2 themes since the previous inspection. These are noted in the body of the inspection. This non compliance is ongoing since the inspection August 2015.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • RB1.18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): Licensing has noted ongoing infractions in 2 previous themes.
      • RB1.18A - Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • RB1.25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): Licensing has noted that care plans are not completed on 3-4 PICs in each of the Care Aide binders.
    • 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): Medication Safety and Advisory Committee (MSAC) meetings are not being conducted every 6 months per Golden Life's Policy. This is an ongoing non compliance since the previous inspection of July 2016. A discussion of MSAC follow up occurred in January 2017 in which a medication error concern was referred to the MSAC. To this date the MSAC meeting has not occurred.
      • R2.1N - Establish and review policies and procedures on safe and effective storage, handling and administration of medications; 68( 3 )(b)(i)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Licensing has noted during an employee file review CRCs were not completed on 2 employee files. Previous CRC on one employee expired November 2016. The RCMP finger print documentation for this employee is on file, and to this day of inspection has not been sent to the ministry to renew the CRC. A new kitchen staff does not have a completed CRC on file.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing observed inconsistent monthly weight recordings in (PIC) records. Weight measurements for a PIC is missing 2 weights for a 6 month period. Another PIC documentation has 2 weights documented in a 7 month period. This non compliance has been ongoing since August 2015.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 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): Treatment Administration Records (TAR) are incomplete. Daily dressing changes noted on the care plan to be daily, are documented 4-5 days in a 7 day period. Daily BP's for a PIC which were ordered by the physician daily, are documented 5 out of 7 days on 2 different occasions. Licensing has noted that care plans are not completed on 3-4 PICs in each of the Care Aide binders.
      • 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)
15. MonitoringJul 19, 2016

    8 infractions

    • RB1.17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
      • Observation(s): Licensing observed that the most recent inspection was not posted.
      • RB1.17A - Post the most recent routine inspection in a prominent place.
    • RB1.18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): Licensing noted ongoing infractions in 3 themes.
      • RB1.18A - Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing observed ongoing non compliance in 3 themes since the previous inspection. These are noted in the body of the inspection. There is an ineffective process in place to monitor the physical environment and the care and services provided. This non compliance is ongoing since the previous inspection.
      • 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): Licensing observed that the monthly fire drills are not being conducted regularly. There is an ineffective process in place to ensure this occurs monthly. MSAC (Medication Safety Advisory Committee) meetings are not being conducted regularly. There is an ineffective process in place to ensure this occurs regularly
      • R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
      • R2.1N - Establish and review policies and procedures on safe and effective storage, handling and administration of medications; 68( 3 )(b)(i)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing observed inconsistent monthly weight recordings in Person in Care (PIC) records. Weight recording in an ongoing contravention since the previous inspection.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing observed that the tracking of fridge temperatures is inconsistently being monitored. This is an ongoing infraction since the previous inspection.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing observed prescription medications are left in PIC rooms in an unlocked cupboard and accessible to PIC. This is an ongoing infraction since the previous inspection.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): MSAC meetings and inspection of medication storage area not being conducted regularly.
      • R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(b)
16. MonitoringAug 28, 2015

    9 infractions

    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): Reportable incident list for staff use is out of date, does not reflect current Residential Care Regulations Schedule D.
      • Retain a record of reportable incidents involving persons in care; 88(c)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): Bedside daily care directives do not adequately reflect fall prevention strategies as recommended by nursing or physiotherapy/occupational therapy professionals.
      • 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)
    • 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): Signed consents for "Foot Care Nursing" / "Foot Care Nurse" on multiple persons in care files, however, foot care services provided in house are offered by both nursing and non-nursing contracted partners. Emergency policies indicate last review date 2011-2013. Emergency policy binder difficult to navigate, no tabs or quick reference for locating needed policy in urgency. Admission assessment, including physical review and safety screening, not completed on person in care file.
      • Advise of all charges/fees/other payments for accommodation/other services offered prior to admission; 48( 1 )(a)
      • Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • Make all policies and procedures available to employees at all times, to licensing, a person in care and the parent/representative on request; 85( 1 )( c) (i)(ii)(ii.1)(iii)
      • 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): Unable to locate proof of Tuberculosis screening or, in case of staff with positive Tuberculosis screen, unable to locate proof of x-ray or physician's clearance, on multiple staff files. Unable to locate performance evaluation on multiple staff files. First Aid certificate expired on multiple person in care files.
      • 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)
      • Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Incorrect sex listed on person in care file.
      • Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78( 1 )(a) Director of Licensing Standards of Practice: Immunization records
    • 4.6 Are facility records current and complete?
      • Observation(s): Complaint record does not include dates on which actions were taken as part of follow-up process.
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Snacks do not consistently contain items from 2 food groups.
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Multiple items in servery fridge are not wrapped/labelled/dated.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 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): Care plan for French-speaking person in care does not indicate any language for communication. Progress notes on this person indicates that he often attempts to communicate verbally in French. Unable to locate oral care plans on multiple person in care files.
      • 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)
      • Care plans must includes an oral health care plan; 81( 3 )(b)
17. MonitoringApr 7, 2015

    5 infractions

    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Callpoint detailed activity reports (call bell response records) reviewed this date do not promote the health, safety or dignity to persons in care.
      • Provide a monitoring system or signalling device that will signal that a person in care needs immediate assistance; 19(1)(c)
    • 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): Callpoint detailed activity reports (call bell response records) reviewed this date do not promote the health, safety or dignity to persons in care.
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Upon an audit of staff records, three staff records did not have a criminal record check results. In addition two employees did not have diplomas or certificate records. One staff record did not have a copy of a valid first aid and CPR certificate.
      • Ensure criminal record checks are obtained for all employed persons; 37(1)(a)
      • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37(1)(d)
      • Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43(1)(a)(b)(c) (Show More)
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): Upon the audit of staff records, three did not have a criminal record check result on file.
      • Keep employee criminal record check results; 86(a)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Once call bell system is initiated by the resident(s), ensure the call is answered in a timely manner to ensure the health, safety and dignity of person(s) in care and to ensure the person in care's needs continue to be met.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 (1)
18. MonitoringDec 22, 2014

    10 infractions

    • 3.2 Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): At times staffing patterns do not promote the health, safety and dignity of persons in care as per Residential Care Regulation 42 (1)(a)(b).
      • 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)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): The facility has not been reporting a service delivery problem when shifts or portions of shifts are not replaced. A service delivery problem means any condition or event which could reasonably be expected to impair the ability of the licensee or his or her employees to provide care, or which affects the health, safety or dignity of persons in care are per Residential Care Regulation 77 (1)(a)(i)(2)(3) (a)(b)(c)(d).
      • Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77(2)(a)
      • Immediately notify the medical or nurse practitioner responsible for the person in care involved in a reportable incident; 77(2)(b)
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77(2)(c)
      • Immediately notify the funding program, if any, if a person in care is involved in a reportable incident; 77(2)(d)
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Some call bell response records reviewed do not promote the health, safety and dignity of persons in care as per Residential Care Regulation 19 (1)(c).
      • Provide a monitoring system or signalling device that will signal that a person in care needs immediate assistance; 19(1)(c)
    • 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): At times staffing patterns do not promote the health, safety and dignity of persons in care as per Residential Care Regulation 42 (1)(a)(b). Some call bell response records reviewed do not promote the health, safety and dignity of persons in care as per Residential Care Regulation 19 (1)(c).
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Some employee records audited were not up-to-date. A criminal record check, character references and two first aid/CPR tickets had expired.
      • Ensure criminal record checks are obtained for all employed persons; 37(1)(a)
      • Obtain character references for all employed persons; 37(1)(b)
      • Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43(1)(a)(b)(c) (Show More)
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): One staffing record reviewed on December 30, 2014 did not have a criminal record check results. In addition there was no documentation of an employee character reference check as per Residential Care Regulation 86(a)(b),
      • Keep employee criminal record check results; 86(a)
      • Keep employee character references; 86(b)
    • 4.6 Are facility records current and complete?
      • Observation(s): The licensee currently does not retain records of complaints or concerns expressed under section 60 and the responses to them as per Residential Care Regulation 89(11).
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 (11)
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): 1) Expired milk product found in resident's fridge in dining area. Ensure all food is safely stored as per Residential Care Regulation 63 (1).
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): 1) Fire extinguishers reviewed this date were expired as of October 2014. Ensure emergency equipment is maintained on a regular basis as per Residential Care Regulation 22 (3). 2) Infraction from previous inspection done 30-Dec-2013 - (6) Medication room door lock is broken and cannot be locked. RESOLVED
    • 10.1 Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): The license must consider the number of employees and staffing patterns of employee coverage before admitting persons in care to ensure the health, safety and dignity of persons in care as per Residential Care Regulation 47(2)(a).
      • Ensure the screening process considers the training and experience of employees, the number of employees and patterns of employee coverage; 47(2)(a)