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Columbia House

1030 10 St Invermere BC V0A 1K0 · Residential Care - Licensing

Official record from Interior Health →

Inspection summary

Columbia House has been inspected 12 times by Interior Health Authority since April 13, 2015. The most recent inspection, on November 19, 2025, recorded 3 infractions.

None of the 12 inspections on record were free of infractions. In the past 12 months there was 1 inspection with 3 infractions recorded. 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 These findings are administrative: the documentation was missing or out of date at the time of inspection.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 22 times across 10 separate inspections, most recently on November 19, 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 6 separate inspections, most recently on December 12, 2023. 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 once on September 6, 2016. For example: RB1.22 - 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 30 times across 12 separate inspections, most recently on November 19, 2025. For example: 2 - Is the environment maintained to prevent falls?

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.

12 inspections

  1. Routine Inspection

    3 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): R7.2R - During the inspection of the physical facility it was identified that a person in care accesses and utilizes the laundry facilities located in the hairdressing room. The flooring in this area did not contain a slip-resistant floor surface. It was also noted that the door to this room was unlocked at the time of the inspection. The Long Term Care Coordinator confirmed that, moving forward, the door will remain locked when not in use by approved volunteers or persons in care. The absence of slip resistant flooring in the laundry facilities presents a safety and slipping hazards to persons in care. Submit by December 5, 2025, a written plan outlining how the contravention related to ensuring that laundry facilities have a slip resistant floor surface, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 35(2)(a) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
    • 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 - During a review of medication administration records, a handwritten label was identified. The label did not contain a date, the associated documentation was incomplete, and there was no record of the order being faxed to the pharmacy. The current system for receiving and processing medication orders was reviewed with the Licensed Practical Nurse, the Long Term Care Coordinator, and manager during the inspection. It was confirmed that the Medication Management: Long-Term Care Nursing Policy was not followed. Failure to follow the medication management policy may increase the risk of medication errors, which may result in harm to persons in care, including adverse drug reactions or ineffective treatment. Submit by December 5, 2025, a written plan outlining how the contravention related to ensuring that the medication management policy is being 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): R6.3B - During the inspection of the physical facility, it was noted that a fridge accessible to persons in care was not locked as required by facility procedures. This was observed outside of a scheduled meal service timeframe. This poses a potential risk to the safety and quality of stored food, which may impact the health and well-being of persons in care. Submit by December 5, 2025, a written plan outlining how the contravention related to ensuring that food is safely stored, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 63(1) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  2. 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 system to ensure that each day at least 2 nutritious snacks with at least 2 food groups is provided is ineffective. It was noted during the inspection that the current menu does not provide 2 daily snacks with at least 2 food groups.
      • 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)
  3. Routine Inspection

    5 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing acknowledges effort to increase self-monitoring of the care and services provided through the development of multiple care and services audits. During the inspection it was identified that food service audits were not completed as per guidelines, and a previously submitted health and safety plan for food services was not being followed. This is also noted by the number of contraventions identified within this report. This is a re-occurring contravention from the January 2023, and December 2023 inspections.
    • 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 system to ensure policies are implemented by employees is ineffective. During a random chart audit it was identified that a person in care with aggressive behaviours did not have the identifier on the care plan as per the policy. This is a re-occurring contravention from the December 2021 and December 2023 inspections. The policies not being implemented during the 2021 inspection were related to the orientation of managers; the policy not being implemented during the 2023 inspection was related to admission criteria.
      • 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): The system to ensure each person in care has their weight taken and recorded monthly is ineffective. It was noted during the inspection that a person in care had multiple missed months of a weight being recorded.
      • R4.1U - 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): It was noted during the inspection that the system to ensure fridge temperatures are monitored for food safety is ineffective. The temperature tracking documents contained multiple missed entries, as well as no documentation to evidence if any corrective actions were taken when the temperature was noted to be out of the accepted range. This is a re-occurring infraction from the November 2021, June 2022, and July 2023 inspections.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It was noted during the inspection that the system for ensuring persons in care receiving ongoing tray service are reassessed at least once every 30 days is ineffective. During a random chart audit two persons in care who receive ongoing tray service had not been reassessed every 30 days. This was noted by the reassessment tracking document located in the charts having months with no recorded documentation.
      • 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)
  4. Routine Inspection

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing acknowledges effort to increase self-monitoring of the care and services provided via the development of multiple care and services audits. However, monitoring to ensure compliance is ineffective as noted by the contraventions in this report. This is a re-occurring contravention from the January 2023 inspection.
    • 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): Through random chart audits completed during this inspection it was identified that the system to ensure policies related to new admissions are being implemented by employees is ineffective.
      • 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 the weekly menu is displayed in a prominent place in each dining area is ineffective. It was identified that the menu located in one unit was displayed behind a room divider where persons in care do not have access. This is an on-going infraction from the May 2023 inspection. This contravention was corrected during the inspection.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It was identified during the inspection that persons in care who may leave the facility without notifying an employee, do not have identification that cannot be easily removed containing the person in care's name, facility, and emergency contact information. This is an re-occurring contravention from the June 2022 and January 2023 inspections.
      • 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)
  5. Routine Inspection

    4 infractions

    • 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 as needed medication (PRNs) effectiveness was inconsistently documented. This is a re-occurring contravention from the November 2021 inspection.
      • R3.1X - 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): It was noted during the inspection that the system to ensure fridge temperatures are monitored for food safety is ineffective. This is a re-occurring infraction from the November 2021 and June 2022 inspections.
      • 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): The system to ensure the weekly menu is displayed in a prominent place in each dining area is ineffective. During a random room audit a medicated cream was noted to be accessible to persons in care as it was on a bedside table. This contravention was identified on the previous inspection in January 2023. This contravention was corrected during inspection. The system for ensuring all medications are safely and securely stored will be updated to include process for respite beds.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 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 are updated following a change was ineffective. During a random audit of care plans it was noted that a care plan indicated a restraint that was no longer in use. This is a re-occurring contravention from the November 2021 inspection.
      • 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

    8 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): During the inspection it was noted that the system to ensure restraint monitoring is completed is ineffective. Restraint monitoring documents were inconsistently completed. This is an on-going contravention from the previous inspection.
      • 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)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): During a file review prior to the inspection, as well as a random chart audit during the inspection, this Licensing Officer identified reportable incidents not reported to Licensing as required by the legislation. This is an on-going contravention from the previous two inspections.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): There is currently no system in place to ensure the most recent routine inspection report is displayed in a prominent place in the facility. The system for self-monitoring is ineffective as noted by the number of contraventions identified in this report, as well as the number of on-going and reoccurring contraventions identified.
      • R1.1O - 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)
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • 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): There is currently no system in place to ensure the most recent routine inspection report is displayed in a prominent place in the facility.
      • RB1.17A - Post the most recent routine inspection in a prominent place.
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): During a random physical site audit it was noted that a laundry room door was open and accessible to persons in care, with no staff present. During a random room audit it was identified that the system to ensure all medications are safely and securely stored is ineffective. Medicated creams were noted to be accessible to persons in care in one bedroom as they were stored on a night stand, and the bathroom counter. This is an on-going contravention from the previous inspection.
      • R7.1AM - Ensure that laundry facilities if not used by persons in care, cannot be accessed by persons in care; 35( 2 )(b)
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): It was identified during the inspection that there is currently no system in place to ensure there is a medication safety and advisory committee.
      • R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It was identified during the inspection that persons in care who may leave the facility without notifying an employee, do not have identification that cannot be easily removed containing the person in care's name, facility, and emergency contact information. This is an on-going contravention from the previous inspection.
      • 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): Of the charts reviewed, it was identified that the system to ensure oral care plans are included is ineffective. It was noted that there is no indication of each person in care's specific needs related to oral care. This is an on-going contravention from the previous inspection. The system to ensure there is a plan in place for persons at risk of leaving the facility is ineffective. Persons in care identified as a risk of leaving the facility did not have a care plan to prevent, or respond should the person leave without notifying employees.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
      • R10.3G - Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
  7. Routine Inspection

    7 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): During the inspection it was noted that the system to ensure restraint monitoring is completed was ineffective. Restraint monitoring documents were inconsistently completed. This is a recurring infraction from the previous inspection.
      • 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)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): During a file review prior to the inspection, as well as a random chart audit during the inspection, it was identified that licensing has not been notified of reportable incidents as per the legislation. This is a recurring infraction from the previous inspection.
      • 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): Upon a random audit of charts, it was noted that multiple fall prevention plans did not contain a plan for preventing the person in care from falling.
      • R10.4P - 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): It was noted during the inspection that the system to ensure fridge temperatures are monitored for food safety was inconsistent. This is a recurring infraction from 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): During a random room audit it was identified that the system to ensure all medications are safely and securely stored is ineffective. Medicated creams were noted to be accessible to persons in care in two separate rooms on the bathroom counters.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It was identified during the inspection that persons in care who may leave the facility without notifying an employee, did not have identification that cannot be easily removed containing the person in care's name, facility, and emergency contact information. The system to ensure ongoing room tray service is indicated in the care plan, approved, and reassessed by the medical practitioner, or dietician at least once every 30 days was ineffective.
      • 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)
      • R10.2V - 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)
    • 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): Of the charts reviewed, it was identified that the system to ensure oral care plans are included was ineffective. It was noted that there was no indication of each person in cares specific needs related to oral care.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  8. Routine Inspection

    7 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): During the inspection it was noted that the system for ensuring restraint monitoring was in place appeared ineffective.
      • 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)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): During a file review prior to the inspection, as well as chart audits during the inspection, it was identified that licensing has not been notified of reportable incidents as per the legislation.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): During the inspection it was noted that the name of the manager was not displayed.
      • 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)
    • 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 managers to the regulations and the Act is being implemented, was ineffective.
      • 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): During the inspection it was noted that employee performance evaluations are overdue. This is a recurring infraction noted from the previous inspection. During a random audit of the medication administration records it was noted that the effectiveness of as needed medications (PRN) were inconsistently documented.
      • 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)
      • R3.1X - 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): It was noted during the inspection that the system to ensure fridge temperatures are monitored for food safety was inconsistent. This is a recurring infraction from the previous inspection.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 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): During a random chart audit, the Licensing Officer was unable to ascertain if a care plan was current as per the legislation. During the inspection, it was noted that the system to ensure the care and supervision of a person in care is consistent with the terms and conditions of the care plan appeared ineffective. This was evidenced by progress notes, as well as discussions with care staff.
      • 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)
      • 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
  9. Routine Inspection

    6 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system for ensuring that there is a record showing the date, amount and time at which ordered medications are given is ineffective. This was evident when conducting a random review of topical administration records (TAR's) and medical administration records (MAR's). Licensing Officer noted that there were numerous missed dates for prescribed topical medicines and some missed dates for medications administered.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The facility has a system in place to reassess the need for a restraint, however, the facility has not been completing reassessments of restraints as per the facility procedure.
      • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The system for ensuring that all residents admitted comply with the Province's TB control program is ineffective. Licensing Officer noted in a random audit of charts some persons in care were missing evidence of TB screening.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Performance reviews of staff have not been completed regularly. Inform Licensing of the system that will be put in place to ensure that each employee is reviewed for performance.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system to capture height and weight upon admission appears to be inconsistently recorded. Some person in care records missing evidence of height and/or weight on admission.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system in place to ensure that food is stored at a safe temperature in the fridges appears to be ineffective. Temperatures recorded regularly indicate temperatures higher than food safe temperatures. The tracking sheet in place does not indicate any evidence of mitigation on this issue. This is a reoccurring contravention from 06-Sep-2016.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  10. Monitoring

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Licensing has noted that their is not immediate access at all times to an employee who holds a first aid and CPR certificate. This is an ongoing contravention.
      • R3.1O - 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)
  11. Monitoring

    8 infractions

    • 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 observed caviwipes in kitchen areas and hallways accessible to PIC to hazardous materials and chemical products. (CDI) Monitoring of medication fridge is not being conducted regularly to ensure the safety of medications stored in fridge. Licensing observed inconsistent documenting of fridge temperatures which does not ensure food is safely stored.
      • RB1.18A - Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • RB1.22 - Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): Staff meetings are being conducted in a area that is accessible to PIC and visitors which does not respect the privacy and personal information of PIC.
      • RB1.22A - Respect personal privacy and keep records and personal information confidential.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing was not notified of the latest Manager change to the interim manager.
      • R1.1E - Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Medication Administration Record (MAR) review found inadequate responses to PRN effectiveness according to the policy of the medication safety and advisory committee. This is an ongoing infraction for 3 previous inspections. Licensing has noted that their is not immediate access at all times to an employee who holds a first aid and CPR certificate. This is an ongoing contravention
      • R3.1O - 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)
      • R3.1X - 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): Licensing observed inconsistent documenting of fridge temperatures which does not ensure food is safely stored.
      • 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 caviwipes in kitchen areas and hallways accessible to PIC to hazardous materials and chemical products. (CDI) Monitoring of medication fridge is not being conducted regularly to ensure the safety of medications stored in fridge.
      • R7.1AJ - Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
      • 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)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Monitoring of medication fridge is not being conducted regularly to ensure the safety of medications stored in fridge. MSAC meetings are not being conducted on a regular basis.
      • R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)
      • R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(b)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Medication Administration Record (MAR) review found inadequate responses to PRN effectiveness according to the policy of the medication safety and advisory committee to ensure the needs of the IC are continuing to be met.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  12. Monitoring

    5 infractions

    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): 1) Staffing records audited were not up-to-date. This includes criminal record checks, character references, work history, copies of diplomas, certificates, performance reviews and valid first aid and CPR certificates. This infraction has been outstanding since 24-Oct-2012. Please note performance reviews are in progress and near completion.
      • Ensure criminal record checks are obtained for all employed persons; 37(1)(a)
      • 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)
      • 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): 1) Height and weight not always documented on admission.
      • Record the height and weight of each person in care on admission; 49 (2)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): 1) In one area of the facility a ceiling tile panel appears brownish in color and appears to have water damaged. 2) Emergency equipment: One fire extinguisher not maintained, expiry date noted was 23-January-2015.
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
      • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 (3)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): 1) Effectiveness or ineffectiveness is not always documented on the medication administration record (MAR). Please note this infraction has been outstanding since an inspection done on 24-Oct-2012.
      • Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68(1)(a)(b)(c) (Show More)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): 1) The effectiveness or ineffectiveness of as needed medication (PRN) is not always monitored to determine if the needs of the person in care 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)

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