Creekside Landing

6190 Okanagan Landing Rd Vernon BC V1H 1M3 · Residential Care - Licensing

13 inspections

1. Substantiated complaintJun 30, 2026

   2 infractions

   • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): During this investigation, it was identified that concerns expressed to the Licensee were not documented as per policy. Failure to follow policy and procedures regarding documentation of concerns and complaints expressed, may compromise the integrity of the complaint resolution process. Submit by July 14, 2026, the plan that will be implemented to come into compliance with Section 85(1) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
     • 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): Allegation: Call bell response times were not done in a timely manner. A licensee must regularly monitor the health and safety of each person in care to determine whether the needs of the person in care continue to be met. A review of the call bell response times identified a lengthy response time. The response time was sufficient on the balance of probability to suggest that the needs of the person in care was not met. Based on the review of evidence the allegation is: substantiated Submit by July 14, 2026, the plan that will be implemented to come into compliance with Section 50(1) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
     • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
2. Routine InspectionMay 28, 2026

   5 infractions

   • 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 the facility is ineffective as noted by the number of contraventions identified in this report, as well as during the inspection, auditing processes was noted to be ineffective or non-existent. For example, there was no system in place auditing monthly weights or bathing. The auditing of the physical environment did not identify safety risks. 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 June 12, 2026, the plan that will be implemented to come into compliance with Section 61 of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
     • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): The system to ensure that Performance reviews are completed as per policy is ineffective. A review of the staffing spreadsheet, and in discussion with the manager, it was identified that performance reviews have not been completed in a timely manner. Regular performance reviews are required to ensure staff are demonstrating the competence required to ensure the health, safety, care and dignity of persons in care. Submit by June 12, 2026, the plan that will be implemented to come into compliance with Section 40(1)(a)(b) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements. The system to ensure that employees are trained in the implementation of emergency plans is ineffective. Staff did not have access or know the whereabouts of the key to unlock the gates in a courtyard. The inability to exit the courtyard in case of an emergency compromises the health & safety of persons in care. Submit by June 12, 2026, the plan that will be implemented to come into compliance with Section 51(3) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
     • R3.1N - 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)
     • R3.1Z - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): The system to ensure that persons in care are weighed monthly is ineffective. A review of the spar records and care plans on point of care identified sporadically missed monthly weights. The records did not contain any additional documentation to indicate any reason for the missing information (e.g., refusal, absence, equipment issues, or clinical rationale). Inconsistent or incomplete weight monitoring increases the risk that significant changes in person in care's health status may go unrecognized or unmanaged. Submit by June 12, 2026, the plan that will be implemented to come into compliance with Section 83(4)(a) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
     • 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): The system to ensure persons in care maintain good hygiene is ineffective. A review of the bathing schedule identified missed baths. There was no evidence of a system to ensure that missed baths were made up and the bathing policy provided no guidance. Inconsistent or incomplete bathing increases the risk that significant changes in a person in care's health status may go unrecognized or unmanaged. Submit by June 12, 2026, the plan that will be implemented to come into compliance with Section 54(1) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
     • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): The system for maintaining the physical environment is ineffective as noted by the observed deficiencies. Patio furniture noted to be dirty and unsanitary with chairs observed to be blocking an exit door. Sheltered areas covered in cobwebs. Cracks and uneven pavement observed in the patio areas which pose a tripping and falls risk. Dug holes in the ground created for work on the irrigation system were not marked off posing a potential tripping hazard. Not maintaining the physical environment to ensure it is clean and safe poses a potential safety risk to persons in care. Submit by June 12, 2026, the plan that will be implemented to come into compliance with Section 22(1)(c) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements. The system to ensure that work areas are safe and secure is ineffective. During the inspection of the physical facility, a soiled linen room door was noted to be unlocked, as well as an open office door containing sharp objects such as scissors and various supplies containing chemicals. Access to rooms that should not be accessible by persons in care poses safety risks. This was also a contravention on the previous inspection. Submit by June 12, 2026, the plan that will be implemented to come into compliance with Section 35(1)(c) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
     • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
     • 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)
3. Routine InspectionDec 9, 2025

   4 infractions

   • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
     • Observation(s): The system to ensure when restraints may be used is ineffective. A review of care plans which identified the use of a restraint, did not have any evidence of a restraint agreement. Failure to have restraint agreements for the use of a restraint may compromise the health, safety and dignity of persons in care. This was also a contravention on the previous inspection. Submit by January 7, 2026, the plan that will be implemented to ensure ongoing compliance with Section 74(1)(b) of the Residential Care Regulation.
     • R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
   • R4.3 - Is documentation concerning restraints adequate?
     • Observation(s): The system to ensure that a restraint that is in continuous use be reassessed include consulting, to the extent reasonably practical, with the persons who agreed to the use of the restraint is ineffective. A review of restraint reassessments lacked evidence supporting that the persons who agreed to the use of the restraint were consulted. Submit by January 7, 2026, the plan that will be implemented to ensure ongoing compliance with Section 84(e) of the Residential Care Regulation.
     • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): The system to inspect and maintain emergency equipment is ineffective as evident of Fire extinguishers past due their inspection dates. Failure to inspect and maintain emergency equipment can potentially compromise the health & safety of the person in care. Submit by January 7, 2026, the plan that will be implemented to ensure ongoing compliance with Section 22(3) of the Residential Care Regulation. The system to ensure that storage areas are safe and secure is ineffective as observed by utility room doors left unlocked. Unlocked rooms which may contain cleaning products or other hazardous materials may increase risk to persons in care if accessible. Submit by January 7, 2026, the plan that will be implemented to ensure ongoing compliance with Section 35(1)(c) of the Residential Care Regulation.
     • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
     • 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): The system to ensure care plans include all the components is ineffective. A review of care plans identified that a care plan for a person in care determined to be at risk of leaving the facility lacked a plan to locate and return to the facility. The absence of specific plans may compromise the health & safety of the person in care. Submit by January 7, 2026, the plan that will be implemented to ensure ongoing compliance with Section 81(3)(f)(ii) of the Residential Care Regulation. The system to ensure care plans are updated is ineffective. A review of a care plan was noted to not have been reviewed or revised as indicated by a monitoring requirement no longer required. Failure to update a care plan can result in care that does not reflect the person's current status or needs. Submit by January 7, 2026, the plan that will be implemented to ensure ongoing compliance with Section 81(4)(b) of the Residential Care Regulation. The system to ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan is ineffective. A review of the HCA flowsheet and restraint monitoring binder identified safety checks, bed alarm checks and restraint monitoring that are sporadically missed. Failure to monitor and document as per the requirements of the care plan can compromise the health and safety of persons in care. Submit by January 7, 2026, the plan that will be implemented to ensure ongoing compliance with Section 82 of the Residential Care Regulation.
     • 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)
     • 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
4. Routine InspectionMay 22, 2025

   9 infractions

   • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
     • Observation(s): A review of Care plans which identified the use of a restraint, did not have any evidence of a Restraint agreement. Failure to have restraint agreements may compromise the health, safety and dignity of persons in care. Submit by June 06, 2025, the plan that will be implemented to ensure ongoing compliance with Section 74(1)(b) of the Residential Care Regulation.
     • R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
   • R4.3 - Is documentation concerning restraints adequate?
     • Observation(s): During a review of a restraint agreement and care plan, it was noted that the duration of the restraint and the monitoring of the person in care during the restraint was not identified. The use of a restraint without identifying the duration and monitoring increases the risk to the person in care's physical safety and emotional dignity. Submit by June 06, 2025, the plan that will be implemented to ensure ongoing compliance with Section 84(d) of the Residential Care Regulation.
     • 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)
   • R7.2 - Is the environment maintained to prevent falls?
     • Observation(s): The system to ensure that all furniture and equipment is maintained in a good state of repair is ineffective. It was observed that a person in cares bed was not in good working order. A bedside table was also observed with its door hanging off its hinge. Not maintaining furniture and equipment may compromise the health, safety and dignity of persons in care. Submit by June 06, 2025, the plan that will be implemented to ensure ongoing compliance with Section 21(c) of the Residential Care Regulation.
     • R7.2N - Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
   • R10.4 - Are restraint and fall prevention plans appropriate?
     • Observation(s): The system to ensure that staff are following the instructions in the care plan respecting the monitoring requirements is ineffective. It was observed that restraint monitoring checklists were sporadically charted. The use of a restraint without consistent monitoring increases the risk to the person in care's physical safety and emotional dignity. Submit by June 06, 2025, the plan that will be implemented to ensure ongoing compliance with Section 73(2)(b)(ii) of the Residential Care Regulation.
     • R10.4F - Employees administering a restraint must follow any instructions in the care plan of the person in care respecting the use of restraints; 73( 2 )(b)(ii)
   • 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 is ineffective as noted by the number of contraventions identified in this report, as well as during the inspection, auditing processes were not identified. For example, the auditing for restraint monitoring had not identified missed documentation or lack of monitoring. A failure to ensure self-monitoring of the facility compromises the overall health, safety and dignity of persons in care. Submit by June 06, 2025, the plan that will be implemented to ensure ongoing compliance with Section 61 of the Residential Care Regulation.
     • 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 system to ensure that all policies and procedures are followed is ineffective. It was observed that a person in care had a bottle of alcohol in their bedroom contrary to facility policy which states that alcohol is to be stored in the locked communication room or medication cupboard. The use and storage of alcohol not administered by the nurse may compromise the health and safety of persons in care. Submit by June 06, 2025, the plan that will be implemented to ensure ongoing compliance with Section 85(1)(d) of the Residential Care Regulation.
     • 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 system to ensure that employees are trained in the implementation of emergency plans is ineffective. Staff did not know the whereabouts of the key to unlock the gates in a courtyard. The inability to exit the courtyard in case of an emergency compromises the health & safety of persons in care. Submit by June 06, 2025, the plan that will be implemented to ensure ongoing compliance with Section 51(3) of the Residential Care Regulation.
     • R3.1Z - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
   • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
     • Observation(s): The system to ensure that employees responsible for handling and serving food is ineffective. A review of the staffing monitoring spreadsheet identified several staff with expired food safe. Incorrectly storing and handling of food may compromise the health and safety of persons in care. Submit by June 06, 2025, the plan that will be implemented to ensure ongoing compliance with Section 63(1) of the Residential Care Regulation.
     • 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 that water accessible to persons in care is not heated to more that 49 degrees Celsius is ineffective. It was identified that there is no system to monitor or record the water temperature in a spar room. Water temperatures exceeding 49 degrees Celsius presents risk for immersion burn. Submit by June 06, 2025, the plan that will be implemented to ensure ongoing compliance with Section 17 of the Residential Care Regulation. The system to ensure that all rooms and common areas are maintained in a safe and clean condition is ineffective. Several person in cares bedrooms were observed to be cluttered with boxes, the rooms were not well maintained. Not maintaining rooms poses a risk to the mental, emotional and physical well-being of persons in care. Submit by June 06, 2025, the plan that will be implemented to ensure ongoing compliance with Section 22(1)(c) of the Residential Care Regulation.
     • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
     • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
5. Substantiated complaintMar 24, 2025

   1 infraction

   • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): Concerns alleged that care plans were not revised or provided sufficient directions to staff. Finding - SUBSTANTIATED. Review of documentation identified that the care plan was not revised to reflect monitoring requirements and ensuring adaptive clothing was used as required.
     • 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 InspectionMay 16, 2024

   4 infractions

   • R10.4 - Are restraint and fall prevention plans appropriate?
     • Observation(s): The system to ensure that staff are following the instructions in the care plan respecting the monitoring requirements is ineffective. It was observed that restraint monitoring checklists were sporadically charted.
     • R10.4F - Employees administering a restraint must follow any instructions in the care plan of the person in care respecting the use of restraints; 73( 2 )(b)(ii)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): The system to ensure that employees responsible for handling and serving food is ineffective. Employees who handle and serve meals to persons in care do not have any food safe training.
     • R3.1T - Ensure employees responsible for the preparation and delivery of food have the necessary experience, competence and training to ensure that food is safely prepared and handled, and meets the nutrition needs of persons in care; 44 ( 1 )(a)
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): The system to ensure that water accessible to persons in care is not heated to more that 49 degrees Celsius is ineffective. It was observed that Coffee carafes in two dining rooms allows persons in care to have potential access to hot water over 49 degrees Celsius. The system for maintaining the physical environment is ineffective as noted by the observed deficiencies; Wall damage in the dinning rooms, hallways and doorways Floor damage resulting from the swing of a door Damaged Kitchen cabinet doors Damaged dishwashers, one with a panel exposing electrical wiring Damaged electrical outlet in a kitchen area Broken coat hook in a person in cares bathroom. The system to ensure that persons in care have the ability to access the outside activity areas in inclement weather is ineffective. It was observed that courtyards either did not have shelter from the sun or inclement weather or that shelters were in a state of disrepair. The system to ensure the menu is displayed in each dining room is ineffective. It was observed that the displayed menu did not contain the snacks and their identifying food groups.
     • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
     • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
     • R7.1AN - Provide outside activity areas that have comfortable seating including a reasonable amount of shelter from sun and inclement weather; 36 ( 1 ) (c)
     • 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): The system to ensure that care plans are monitored on a regular basis to ensure proper implementation is ineffective. Wound care monitoring documentation observed during this inspection was not consistent with the corresponding care plan.
     • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
7. Routine InspectionMar 30, 2023

   4 infractions

   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): During a chart reviewed, it was identified that a client data / contact sheet did not contain a picture or physical identifiers.
     • R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): The system to monitor secure doors was ineffective. It was noted during the inspection that two doors were unlocked, both rooms containing chemical products and other hazardous materials. This contravention was also noted on the previous inspection completed in May 2022.
     • 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 system to ensure ongoing tray service is reassessed at least once every 30 days was ineffective. During a chart review it was noted that renewals were not signed. This contravention was also noted on the previous inspection completed in May 2022.
     • 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): The system to monitor Care plans to ensure proper implementation was ineffective. It was noted that a Care plan and the corresponding 'My Day' plan differed in directives for checking on a person in care. Implementation of Care plans was ineffective. There was no evidence of monitoring or completing daily checks as required in the Care plan.
     • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
     • 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
8. Routine InspectionMar 23, 2022

   3 infractions

   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): It was noted that two closets, both containing cleaning chemicals, were unlocked at the time of the inspection. This contravention was corrected during the 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)
   • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
     • Observation(s): The system to ensure persons in care who may leave the facility without notifying an employee are fitted with identification was ineffective. A person in care was noted to be an elopement risk, however, did not have any identification indicating their name, facility, or emergency contact information. Persons in care who leave the building independently were noted to carry current identification. The system to ensure ongoing tray service is approved, and reassessed at least once every 30 days was ineffective. It was identified in a care plan, as well as in progress notes that a person in care regularly eats meals in bed; however, did not have the appropriate approvals and reassessments in place.
     • 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): Wound care plans were noted to lack clear directions for implementation. The system to ensure that the wound care plans are implemented properly was ineffective.
     • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
9. Routine InspectionNov 22, 2018

   2 infractions

   • RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
     • Observation(s): A person in care's care plan did not include behavioural interventions nor did it address independent outings.
     • RB1.23A - Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
   • 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 in place to ensure care plans include the unique abilities, physical, social, and emotional needs is ineffective. Licensing Officer reviewed a care plan for an individual who leaves the facility independently, and independent outings was not care planned for. The system in place to ensure behaviour care plans are in place for those who experience responsive behaviours is ineffective. Licensing Officer reviewed a care plan for a person in care who under certain circumstances displays responsive behaviours. The care plan did not note behavioural interventions to guide the employees.
     • 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)
10. MonitoringNov 15, 2017

    0 infractions

11. MonitoringSep 13, 2016

    4 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Sep 13, 2016 - UNRESOLVED - The facility's process for ensuring compliance with keeping a record of employee initials on TARs for the administration of routinely prescribed medicated treatments has been ineffective. The TARs are missing employee initials for the administration of routinely prescribed treatments. The Care Manager is implementing a new system Oct 01, 2016 for ensuring compliance with keeping a record of the initials for routinely prescribed treatments.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): September 13, 2016 - The facility's processes for monitoring compliance with personal hygiene care items storage and labelling are ineffective. LO located nail clippers, nail files, and a comb in the kitchen drawers in neighbourhood A. These items were removed and discarded during inspection. The facility does not currently have a process in place to ensure compliance with the safe storage of food in person in care's personal fridges. Currently there are no thermometers in the persons in care's personal fridges. There is no documentation for the monitoring of the temperatures or of the food stored in the fridges to ensure the food is safely stored.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): September 13, 2016 - The facility's process for ensuring compliance with the monitoring of the environment in the court yards is ineffective. LO noted a hole in the middle of the pavement on the court yard walk way. This hole measured approx 3 inches X 3 inches and 2 inches deep. Management was unaware of the hole.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): September 13, 2016 - UNRESOLVED - The facility's process for ensuring compliance with keeping a record of employee initials on TARs for the administration of medicated treatments has been ineffective. The TARs are missing employee initials for the administration of routinely prescribed treatments. The Care Manager is implementing a new system Oct 01, 2016 for ensuring compliance with keeping a record of the initials for routinely prescribed treatments. A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care, and (b) the date, amount and time at which the medication was administered. 78 (2) (b)
12. MonitoringFeb 5, 2016

    6 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Missed signatures noted for regularly scheduled treatments noted on the Treatment Administration Record. This item remains outstanding from the past inspection report.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Of the sampling of staff records reviewed there was one staff member missing their immunization screen.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 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): The facility has several policies and procedure manuals which have not been reviewed for several years. This item remains outstanding form the previous inspection report.
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): A sampling of staff records were reviewed and performance appraisals were discussed with the manager. Performance appraisals are behind in getting completed. The manager has a plan in place and is working on getting 10 appraisals completed per month. This item remains outstanding from the past two inspection report.
      • 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)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Wall damage noted to several dining/living rooms as well as several persons in care rooms. Some bedrooms walls have been repaired and needs to be repainted. Carpet noted to be frayed and lifting outside one persons in care bedroom. Two chairs noted to be soiled in one of the dining rooms. One emergency exit was partially blocked by a wheel chair and another emergency exit has a wheelchair very close to blocking an emergency exit. The nurse manager was to remove the remove the wheelchairs from the exits and follow up today. Fire extinguishers throughout the facility were to be serviced in January of 2016.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
      • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It was noted on the care plan that one person in care was deemed an elopement risk. When questioning the staff on whether the person in care may be able to identify themselves or not, the staff member indicated that on the day, the person in care may or may not be able to identify themselves. The person in care does not wear any identification.
      • 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)
13. MonitoringJul 9, 2015

    10 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Several Medication Administration Records were reviewed during the inspection noted to have missing the results of the effectiveness of the PRN medication. The majority of the Treatment Administration Records were not being signed for the regularly scheduled prescribed treatments.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): The majority of the bedroom doors in the locked unit were locked and as per the facility policy, locked doors are considered a restraint. There was no documentation on the care plans indicating the type of restraint being used. The majority of the bedroom doors in the locked unit were locked and as per the facility policy, locked doors are considered a restraint. There was no documentation on the care plans indicating the reason for the restraint. The majority of the bedroom doors in the locked unit were locked and as per the facility policy, locked doors are considered a restraint. There was no documentation on the care plans indicating the alternatives considered to the use of the restraint. The majority of the bedroom doors in the locked unit were locked and as per the facility policy, locked doors are considered a restraint. There was no documentation on the care plans indicating the duration of the restraint and the monitoring of the person in care during the use of the restraint. The majority of the bedroom doors in the locked unit were locked and as per the facility policy, locked doors are considered a restraint. There was no documentation on the care plans indicating the result of any reassessment for the use of the restraint. The majority of the bedroom doors in the locked unit were locked and as per the facility policy, locked doors are considered a restraint. There was no documentation on the care plans indicating the record of employee compliance while using the restraint.
      • Record the type or nature of the restraint used in the person's care plan; 84(a)
      • Record the reason for the use of restraint in the person's care plan; 84(b)
      • Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
      • Keep a record of employee compliance with the requirements of Division 5 (Use of Restraints) of Part 5 in the persons care plan; 84 (f)
    • 10 -Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
      • Observation(s): Family council meetings have not taken place for over 1 year.
    • 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): The facility has several policy manuals of which policies have not been noted to be reviewed for several years. There is a policy on performance evaluations which was updated in 2014 but the policy did not include performance evaluations for probationary periods. Nurse manager stated that performance evaluations are completed during the probationary period but the staff records do not reflect this. The policy on performance evaluations is incomplete and does not reflect what the facility is practicing. There is a restraint policy indicating that locked doors are considered a restraint. The majority of the bedrooms of the persons in care rooms in the locked unit were locked. The restraint policy was not being followed in regards to care planning for this type of restraint, consents and monitoring. The date of follow up for this infraction is August 6, 2015.
      • Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): A sampling of several staff records were reviewed during the inspection. Several staff members did not have performance reviews on file. This remains outstanding from the past inspection.
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): A sampling of person in care records were reviewed during the inspection and two care records noted to have missing physical identifiers in which a person may be described in an emergency. A sampling of person in care records were reviewed and consents to call a medical or nurse practitioner or ambulance was not on record. The nurse manager stated that they have started the process on obtaining these records but no consents were on records as of yet.
      • Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
      • Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The recording of the refrigerator temperature logs were missed on several occasions in several different dining areas and one fridge containing milk only did not have any temperatures being logged.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 5 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The hallways in the locked unit were extensively damaged throughout. The nurse manager stated that wall covering for these areas are in the process of being ordered to be installed. The outside sidewalk had several areas which have settled that have a dipped surface, posing a safety risk to persons in care. The carpet in several areas was noted to be stained and in need of cleaning. The nurse manager stated they have a carpet cleaning schedule in place and cleaning is to be done on a regular basis. The top of the cabinet underneath the TV in one of the communities is damaged. The cupboards doors were missing in the kitchen of one community. Spa room was unlocked and hair dryer was found right nest to sink. Hair dryer was removed to a shelf and door was locked during the inspection. (CDI = corrected during inspection) The hairdresser room door was found to be open and unlocked. Hazardous materials were accessible to persons in care. The door was locked during the inspection. (CDI) Weekly menu not posted in one of the dining areas. Menu posted during the inspection. (CDI)
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • 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)
      • Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 8 )
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): An over the counter antibiotic treatment cream was found unlocked in a persons in care bathroom cupboard. The treatment cream was removed during the inspection. (CDI=corrected during inspection)
      • Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There are resident council meetings taking place at the facility but no family participation noted. In discussion with the manager and nurse manager, it was determined that no family council meetings have been taken place for over one year.
      • Provide at least an annual opportunity for persons in care and their parents or representatives, family members and contact persons to establish councils or similar organizations to represent the interests of persons in care; 59(a)