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Columbia View Lodge

2920 Laburnum Dr Trail BC V1R 4N2 · Residential Care - Licensing

Official record from Interior Health →

Inspection summary

Columbia View Lodge has been inspected 14 times by Interior Health Authority since November 19, 2014. The most recent inspection, on August 25, 2026, recorded 5 infractions.

None of the 14 inspections on record were free of infractions. In the past 12 months there was 1 inspection with 5 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 These findings are administrative: the documentation was missing or out of date at the time of inspection.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 38 times across 14 separate inspections, most recently on August 25, 2026. For example: 2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?

  • 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 August 25, 2026. 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 May 17, 2016. For example: 22- Is personal privacy respected and records and personal information kept confidential?

  • Other findingsLower risk

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

    Recorded 13 times across 11 separate inspections, most recently on August 25, 2026. For example: 1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?

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.

14 inspections

  1. Routine Inspection

    5 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): It was observed that the effects of as needed (PRN) medications administered were not consistently charted. A failed to chart the effectiveness of PRN medications can pose risk to the health and safety of persons in care; not charting may indicate that the use of PRNs is not known. Submit by September 9, 2026 evidence that PRN medication effectiveness is consistently charted.
      • R4.2E - Keep records of compliance with section 70 (administration of medication); 89( 2 )(d)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): It was observed that a restraint agreement had not been updated as required. Failure to update a restraint agreement is contrary to the regulation and may pose a risk to the health, safety and dignity of a person in care. Submit by September 9, 2026 evidence that all persons in care requiring a restraint care plan have been reviewed and a care plan implemented.
      • R10.4N - Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): During this inspection, weight records were reviewed and it was noted that records were not being recorded on the person in care chart *nutrition plan as required. While weight records were taken in the tub room and transcribed to medication records, the manager confirmed that the weight records were not being maintained as required by facility policy. Failure to consistently chart weights may pose a risk to the health and safety of persons in care. Submit by September 9, 2026 evidence nutrition plans are being updated monthly.
      • 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)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): It was observed that the facility menus did not include snacks. While the facility does provide snacks to persons in care, the menu must detail these to demonstrate compliance with the Regulation.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Neighbourhood 200 has notable damage throughout the common area. It was observed that there was no signage regarding electronic surveillance in place; this was corrected during the inspection. Failing to maintain all rooms in a good state of repair may impact the dignity of persons in care. Submit evidence by September 9, 2026 of a plan to ensure compliance with S. 22(1)(b) of the Residential Care Regulation.
      • R7.1G - Display a notice in a prominent place if electronic surveillance is being used to transmit or record images of persons in care or members of the public; 19 ( 3 )
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  2. Routine Inspection

    2 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The process for ensuring that the type of restraint used is recorded in a care plan was not consistently being completed. Upon a random audit of records reviewed, Licensing noted some persons in care had the type of restraint included in the Long Term Care plan. However, the My Day care plans for the same persons in care indicated no restraint was in use. A licensee must include the type of restraint, its use and duration for use in the care plan as per the legislative requirements to ensure health and safety of persons in care. Provide a corrective action plan to Licensing no later than April 18, 2025.
      • 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): The Licensee's process for documenting wound care provision is not consistently being followed by nursing staff. Of a random audit of charts reviewed where wound care was being provided, two charts were noted to not have wound care documentation completed. The Director of Care was able to confirm that the persons in care had received wound care as per their care plans. A licensee is required to monitor the health and safety of the residents to ensure their needs are met. Provide a corrective action plan to Licensing no later than April 18, 2025.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  3. Substantiated complaint

    2 infractions

    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Contravention identified during investigation - During the investigation this Licensing Officer reviewed multiple pieces of documentation that were noted to be incomplete. An assessment was noted to not contain the date when the assessment had been completed, and referral documentation requested by a Behavioural Specialist was not completed.
      • 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): Allegation - The Licensee is in non-compliance with the Residential Care Regulation (RCR) Section 81(3) (a)(ii) as it pertains to care plans including a plan to address behavioural interventions. Finding - UNSUBSTANTIATED. During the investigation this Licensing Officer reviewed the person in care's care plan and behavioural care plan, both of which contained current behavioural interventions. Allegation - The Licensee is in non-compliance with the Residential Care Regulation (RCR) Section 82 as it pertains to ensuring that the care and supervision of a person in care is consistent with the terms of their care plan. Finding - SUBSTANTIATED. During the investigation this Licensing Officer reviewed the person in care's care plan, behavioural care plan, progress notes, and dementia observational system (DOS) records. The DOS records were not completed as written in the person in care's care plan.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(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
  4. Routine Inspection

    6 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The effectiveness of PRNs administered are not consistently charted.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The November 2023 inspection report was not posted.
      • 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)
    • 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): The most recent inspection report was not displayed.
      • RB1.17A - Post the most recent routine inspection in a prominent place.
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Person in care weights are not consistently being recorded in the nutritional plan. Weight refusals are not being documented. This is a repeat contravention.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Water temperature exceeded 49 degrees in Person in Care washroom sinks. (temperature was corrected during the inspection.) Tub room and utility room doors were unlocked. Prescription creams and ointments were not secured.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • 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)
    • 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): Care plans are not being consistently updated annually as required. This is a repeat contravention.
      • 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)
  5. Substantiated complaint

    3 infractions

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Staff did not obtain the required information to correctly complete documentation regarding obtaining consent to health care services.
      • R3.1O - Ensure employees have the necessary training and experience or demonstrate the necessary competence to carry out duties; 40 ( 3 )
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The Decision Maker For Health Care form was incomplete; the facility lacked any information regarding the person in care's incapability and did not have a copy of the representation agreement, even though the form referenced this information.
      • R4.1D - Keep the consent to be admitted or to continue to be accommodated in the community care facility for adult persons in care; 77.1( 1 )(b)
      • R4.1E - Keep each assessment of incapability report for persons in care; 77.1( 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): The person in care's care plan was not updated and didn’t reflect the behavioral interventions that the licensee employed. The person in care's representative was not involved in the behavioral care plan changes.
      • 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)
      • R10.3L - Review and modify a care plan with the person in care's participation to the extent reasonably practical; 81( 4 )(c)
  6. Substantiated complaint

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The complainant expressed concerns about incident reporting after a person in care was reportedly involved in reportable event. Licensing reviewed incident reports from the date the complainant provided and confirmed that an incident report had not been submitted for the event. Licensing finds this complaint to be SUBSTANTIATED.
      • 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)
    • 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 complainant expressed concerns about the Licensee not following their process for care conferences. Reportedly, a person in care did not have a care conference until five months after admission. The Licensee’s policy for care conferences states under section 1.1 “An Interdisciplinary Care Conference is held within the first 6 weeks of admission.” Licensing reviewed the records of care conferences in relation to the person in care and confirmed that the initial care conference was held five and half months after admission. Licensing finds this complaint to be SUBSTANTIATED.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The complainant expressed concerns regarding effective communication and ongoing monitoring in relation to meeting the needs of a person in care. -The complainant stated there was a lack of communication in regards to a person in care's wound. Licensing reviewed relevant documentation which stated a person in care had a pressure sore and three weeks later the documentation revealed it was now a wound. There was a lack of documentation to support the monitoring of this area during that time frame. Licensing finds this complaint to be SUBSTANTIATED. At the time this report is being generated, a wound care treatment plan has been initiated. -The complainant stated there was lack of communication relating to a suggested medication change from a consulting physician. Reportedly, a consulting physician indicated that a medication should be reduced and the complainant expressed concern that this was not done in a timely manner. Licensing reviewed relevant documentation and was able to confirm that the care staff and physician were aware of the suggested change on the date it was received. Licensing finds this portion of the complaint to be UNSUBSTANTIATED. -The complainant expressed concerns about the medication monitoring for a person in care and possible lack of pharmacist oversight. Licensing reviewed relevant documentation and confirmed that medication review with a pharmacist, Long Term Care Coordinator and the person in care’s physician had occurred. Licensing finds this complaint to be UNSUBSTANTIATED. -The complainant expressed concerns with the toileting routine for a person in care and that the person in care’s needs were not being met. Licensing reviewed the Licensee’s system for call bell responses and relevant documentation which indicated that toileting was being offered and at times refused. In review of this information, Licensing finds this complaint to be UNSUBSTANTIATED.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  7. Routine Inspection

    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): The system in place to ensure policies are implemented by employees appeared to be ineffective. This was noted when a resident who had been flagged as having aggressive behaviors did not have the alert included their care plan.
      • 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 implemented to ensure all residents are weighed monthly was ineffective. Licensing noted some residents had not been weighed in several months. This is an outstanding contravention from 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)
    • 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 current system in place to ensure all care plans are reviewed, at minimum annually if there is not a change in a person in care's status, was noted to be ineffective. Licensing noted numerous managed risk agreements that had been due for review within the past 1 to 2 years.
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  8. Routine Inspection

    4 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 the licensee is keeping records of the date and time at which medications are administered appeared ineffective as evidenced by the comments below: In a random review of medication administration records (MARs), licensing noted a MAR which did not have anything recorded as given for numerous scheduled medications for the month of March. The resident was noted to be self-administering the medication, however, there is no record of the date or time the medication was taken. In random audit of Treatment Administration Records (TARs), licensing noted that there were numerous scheduled medications which were not documented as given.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The system for ensuring all residents have a fall care plan which outlines the residents' risk of fall and preventative measures from falling appeared to be inconsistent. The licensee is currently changing their care planning format. Some of the new care plans were noted to have the required information, however, some of the new My Day care plans did not have any fall intervention information.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system for ensuring that monthly weights are recorded appeared ineffective. Some residents were noted to have not been weighed for 3 months.
      • 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)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The system to ensure that any resident that self-medicates has a plan in place which is approved by the MSAC and physician appeared to be ineffective. In a random audit of Medication Records, licensing noted a resident to be self administering medication which was not mentioned in their care plan.
      • R9.1G - Permit self-administration of medication when a plan is approved by the medication safety and advisory committee and medical or nurse practitioner, and is included in the person's care plan; 70( 4 )(a)(b)
  9. Routine Inspection

    2 infractions

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system for ensuring the effectiveness of PRN medications are documented appeared ineffective. In a random audit of medication administration records licensing officer noted numerous PRN medications documented as given, without a response noted.
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • 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): Upon a random audit of care plans, licensing officer noted that the oral care plans did not contain direction as to what type of care is required.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  10. Routine Inspection

    7 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 medicated creams are documented as given is ineffective. The majority of TARs were noted to be unsigned. This is an outstanding infraction from previous inspection on August 8, 2019.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system for ensuring all reportable incidents were reported as required appeared ineffective. Upon inspection licensing noted an incident which was not reported as required.
      • 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): The system for self monitoring appears to be ineffective. It appeared upon inspection that there is no current system in place for conducting internal audits.
      • 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): On review of facility process for identifying AGG alerts, it was noted that this process was ineffective. Upon random audit of resident records, it was noted the flagging system was inconsistently being followed.
      • 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): It was noted that the system for obtaining person in care's monthly weights was ineffective. Monthly weights were observed to be inconsistently recorded.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It was observed that the weekly menu was not displayed in each dining room. The daily menu was posted in each dining room.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
    • 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 behaviour care plans, it was noted that behaviours were clearly stated; however, interventions to address the behaviours were not consistently provided in the care plan. In review of medication care plans it was noted that they were inconsistently updated/reviewed. Multiple medication care plans were unclear as to the most up to date plan, as evidenced by items crossed off, or highlighted.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • 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 Inspection

    4 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 medicated creams are documented as given is ineffective. The majority of TARs were noted to be unsigned. This is an recurring infraction.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • 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): See R10.2 above.
      • RB1.18A - Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system for ensuring that emergency exits are not obstructed appeared to be ineffective as licensing noted furniture to be blocking an exit.
      • R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): On numerous records, details around who could take persons in care out of the facility was not clearly articulated.
      • R10.2Q - Only a parent or representative or a person authorized in writing by that person can release or remove a person in care from the facility; 58( 1 )(a)(b)
  12. Monitoring

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Although the MARs were noted to be consistently completed, the system for ensuring that medicated creams are documented as given is ineffective. The majority of TARs were noted to be unsigned.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The system in place to ensure that residents have an immunization status on file is ineffective. Upon a random audit, LO noted that residents had a status for influenza but there was a lack of immunization status on file beyond flu.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
      • R6.2B - Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system in place for ensuring that all residents admitted to the facility, whether respite or permanent have a height and weight recorded on admission is ineffective. Numerous records reviewed were missing the height and weight documented on admission.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 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): The system for ensuring that all care plans are reviewed/revised, at minimum annually appears to be ineffective. In review of resident's medication care plans, LO was unable to ascertain if they had been reviewed/revised within the past year as the majority of the plans were not dated.
      • 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)
  13. Monitoring

    9 infractions

    • 8.1 Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Licensing observed that the facility is not tracking and ensuring PIC are participating in Recreational program of activities provided or activities available in the community.
      • Encourage persons in care to participate in the program of activities provided (Does not apply to Hospice); 55( 1 )(b)(i)
      • Encourage persons in care to take advantage of physical, social and recreation opportunities available in the community (Does not apply to Hospice); 55( 1 )(b)(ii)
    • 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 that hazardous chemicals are left on top of a unsupervised housekeeping cart which is accessible to Person's in Care (PIC) Licensing observed in a nursing area accessible to PIC, caviwipes, which is a hazardous chemical accessible to PIC It was noted that in the inner courtyard there is uneven sidewalks transitions, which is a safety hazard to PIC.
      • Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): Licensing observed that private and confidential Person's in Care (PIC) records are left accessible to PIC, family, and visitors. The charts of PIC are not secured in a locked area.
      • Respect personal privacy and keep records and personal information confidential.
    • 25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): Care plan review noted: Process in place in ineffective to identify and ensure the persons at risk of leaving the facility are identified and an elopement care plan is implemented.
      • Ensure care plans are developed within 30 days.
      • Ensure care plans include all required elements.
    • 3.1 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. Non-compliance with PRN effectiveness has been noted on 2 consecutive inspections.
      • Provide sufficient time for persons in care to participate in activities (Does not apply to Hospice); 45(c)
      • Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing observed that the monthly weights are not consistently recorded. There is an ineffective process in place to monitor this for completion. Licensing observed that private and confidential Person's in Care (PIC) records are left accessible to PIC, family, and visitors. The charts of PIC are not secured in a locked area.
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
      • Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • 4.6 Are facility records current and complete?
      • Observation(s): Medication Administration Record (MAR) review found inadequate responses to PRN effectiveness according to the policy of the medication safety and advisory committee. Non-compliance with PRN effectiveness has been noted on 2 consecutive inspections.
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing observed that hazardous chemicals are left on top of a unsupervised housekeeping cart which is accessible to Person's in Care (PIC) Licensing observed in a nursing area accessible to PIC, caviwipes, which is a hazardous chemical accessible to PIC (CDI) It was noted that in the inner courtyard there is uneven sidewalks transitions, which is a safety hazard to PIC.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 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 review noted: Process in place in ineffective to identify and ensure the persons at risk of leaving the facility are identified and an elopement care plan is implemented.
      • 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)
  14. Monitoring

    4 infractions

    • 4.6 Are facility records current and complete?
      • Observation(s): The effectiveness of PRN medications are not being consistently documented. Ensure the effectiveness of PRN medications is consistently documented as per the Residential Care Regulation section 68 (4). COMPLETION DATE DECEMBER 23, 2014.
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Upon a chart audit, some charts indicated to look at the care plan for vaccination status, but on the care plan there was no current date for influenza vaccine. It was later noted to be in the progress notes that the vaccine had been given. Some residents were missing the pneumococcal vaccination status. COMPLETION DATE: DECEMBER 23, 2014.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 (9)
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Two separate storage rooms with signs on the door stating "keep locked" were found to be open.
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35(1)(c)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): Upon review of resident charts, it was noted that one resident did not have a falls care plan in place. CORRECTION DATE: DECEMBER 23, 2014.
      • 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)

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