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David Lloyd Jones Home

934 Bernard Ave Kelowna BC V1Y 6P8 · Residential Care - Licensing

Official record from Interior Health →

Inspection summary

David Lloyd Jones Home has been inspected 9 times by Interior Health Authority since July 20, 2016. The most recent inspection, on May 27, 2026, recorded 5 infractions.

None of the 9 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.

The number of infractions per inspection has stayed roughly the same over time.

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 These findings are administrative: the documentation was missing or out of date at the time of inspection.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 23 times across 8 separate inspections, most recently on May 27, 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 7 times across 7 separate inspections, most recently on September 24, 2025. For example: 1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?

  • 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 19 times across 8 separate inspections, most recently on May 27, 2026. For example: 3 - Is documentation concerning restraints adequate?

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.

9 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): A review of the Treatment Administration Record (TAR) indicates that medications are not being consistently signed. In one instance, 27 out of 54 entries were not signed. In another instance, a medication was not signed for on 2 out of 4 occasions. Failure to document medication administration increases the risk of missed doses or duplicate administration. Submit to Licensing by June 15, 2026, a plan outlining how TARs will be signed to indicate whether medications have been administered. The plan must identify the steps that will be taken to achieve compliance, as well as the measures that will be implemented to ensure ongoing compliance. This was also a noted contravention at the previous routine inspection.
      • 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): A review of restraint monitoring documentation indicates that, for one person in care, restraint checks were often only documented until 1430. There is no documentation indicating that the restraint was removed or that monitoring was no longer required at that time. When restraint monitoring is not fully documented, it is difficult to confirm that the restraint is being used safely, appropriately, and in accordance with the restraint agreement. Submit to Licensing by June 15, 2026, a plan outlining how restraint monitoring documentation will reflect the current plan for restraint monitoring. The plan must identify the steps that will be taken to achieve compliance, as well as the measures that will be implemented to ensure ongoing compliance.
      • 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)
    • 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 observed that one exit door is blocked with a panel. Upon reviewing the posted emergency plan, this door is identified as an emergency exit; however, discussion with the Manager confirms that the door is no longer intended to be used as an emergency exit. When emergency plans are not kept up to date to reflect current exit routes, it may result in delays during evacuation in the event of an emergency. Submit to Licensing by June 15, 2026, a plan outlining how emergency plans will be updated to reflect current exits and procedures if necessary. The plan must identify the steps that will be taken to achieve compliance, as well as the measures that will be implemented to ensure ongoing compliance.
      • R2.1H - Update emergency plans if there is any change in the facility; 51 ( 2 )
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): A review of as-needed (PRN) medication records indicates that effectiveness is not being consistently documented. In one instance, 13 out of 30 administrations were not followed up on. In a second instance, none of the five administrations were followed up on. When the effectiveness of a PRN medication is not documented, it increases the risk of inadequate symptom management and inappropriate or unnecessary administration. Submit to Licensing by June 15, 2026, a plan outlining how the effectiveness of PRN medications will be documented. The plan must identify the steps that will be taken to achieve compliance, as well as the measures that will be implemented to ensure ongoing compliance.
      • R3.1AA - 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): It is noted that one care plan does not include information to address a specific social and/or emotional need. When specific needs are included in care plans it helps to mitigate the risk of reactive care. Not addressing certain needs within the care plan may also lead to inconsistent staff responses if staff are not aware of the plan. Submit to Licensing by June 15, 2026, a plan outlining how care plans will take into account all needs and preferences of the person in care as legislatively required. The plan must identify the steps that will be taken to achieve compliance, as well as the measures that will be implemented to ensure ongoing compliance.
      • 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)
  2. Routine Inspection

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Medication Administration Records (MARs) were reviewed; several treatment administration records were not signed off as completed. Failure to complete treatment admission records can pose serious risk to persons in care leading to medication errors and compromised care. Please submit a corrective action plan by October 16, 2025, advising how current and future treatment administration documentation will be completed in an accurate and efficient manner.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Dining room refrigerator accessible to persons in care observed to have un-labelled food item. Un-labelled food items pose risk to persons in care as it cannot be safely monitored for contamination. Please submit a corrective action plan by October 13, 2025, advising how all food items accessible to persons in care will be stored in safe and secure manner.
      • 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): Cupboard in person in care bathroom that contained topical medicated ointments was observed to be left unlocked and accessible to persons in care. An unlocked cupboard containing medications can pose risk of harm as persons in care may access and ingest their own medications incorrectly or other persons in care may access medications not prescribed to them. Please submit a corrective action plan by Oct 16, 2025, advising how all medications will be stored in a safe and secure manner.
      • 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 determined that there is currently no system in place to ensure that persons in care who leave the facility have written documentation containing contact information to identify person in care name, facility name and emergency contact information. Without written identification and contact information for persons in care who may leave the facility poses a risk of harm to maintain safety and possible risk of delayed response for any emergency preparedness. Please submit a corrective action plan by Oct 16, 2025, advising what system will be put in place to ensure persons in care will have written documentation (name, facility name, emergency contact information) when leaving the facility and how this process will be maintained.
      • R10.2L - Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56( 1 ) ( 2 )
  3. Routine Inspection

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The Licensee's system to ensure that licensing is immediately notified of all reportable incidents was found to be ineffective. During the inspection, discussions were had regarding reportable incidents. The next day the manager identified two incidents that should have been reported to Licensing, but were not. The manager submitted the reportable incidents as requested and a health and safety plan was also submitted to licensing at that time.
      • 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 Licensee's system to ensure policies are implemented by employees was found to be ineffective. During the inspection, a monitoring document for refrigerator temperature was reviewed and was noted to be missing five temperature checks for the month of November.
      • 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): The Licensee's system to ensure food is safely stored was found to be ineffective. During the inspection, a refrigerator in one of the medication rooms was found to have expired food in it.
      • 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 Licensee's system to ensure medication is securely stored was found to be ineffective. During the inspection, it was noted that a medication cart was left unlocked and unattended during a medication pass. The cart was located in a main area of the facility during meal time. Another medication was noted to be left unattended in a medication cup on the same medication cart, also during meal time.
      • 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 Licensee's system to ensure missed baths are recorded when completed was found to be ineffective. During the inspection, bathing records were reviewed and noted to be incomplete. The document indicated that some baths were missed due to staffing; however, there was no follow up noted to indicate if the baths were made up or not.
      • 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

    5 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The Licensee's system to ensure that topical medication administration records (TAR) are complete was found to be ineffective. During the inspection, one TAR was noted to be missing eleven signatures over the course of a month.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The Licensee's system to ensure that licensing is immediately notified when a person in care is involved in a reportable incident was found to be ineffective. During a review of the facility file, it was identified that since the last inspection in April 2023, two reportable incidents were not sent into licensing as required and were discovered by licensing through review of other incident reports.
      • 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 Licensee's system to ensure that refrigerator temperatures are recorded as required was found to be ineffective. During the inspection, it was noted that temperature checks are required twice a day if a vaccine is being stored. Despite there being a vaccine in the refrigerator, temperature checks were only being completed once a day.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The Licensee does not have a system in place to ensure that employee performance is reviewed regularly. During the inspection, it was noted that no employee performance evaluations have been conducted since the manager started in 2021. This was noted as a contravention on the March 2022 inspection report and as a comment on the April 2023 inspection report. During the April 2023 inspection it was noted that there was a plan in place to complete the performance evaluations; however, no evaluations have been completed.
      • 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)
    • R4.6 - Are facility records current and complete?
      • Observation(s): The Licensee's system to ensure that records are current was found to be ineffective. During the inspection, a document was noted to include directions for follow-up; however, the persons included in those directions are no longer employed at the facility.
      • R4.6L - Ensure all records are current; 91( 1 )(a)
  5. Routine Inspection

    8 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The Licensee's system to ensure that treatment administration records are complete was found to be ineffective. During the inspection, four charts were observed. In one chart, nine out of twelve and eight out of twelve signatures were missing. In the second chart, an order for treatment to occur every three days and on an as needed basis to indicate that care was provided was not signed off for seven days. The Licensee's system to record the effectiveness of PRN (given on an as needed basis) medications was found to be ineffective. During the inspection, four charts were observed. In one chart, six out of fourteen PRN medications did not have the effectiveness of the medication documented. In a second chart, seven out of twenty-one medications did not have the effectiveness documented.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The Licensee's system to ensure that licensing is immediately notified when a person in care is involved in a reportable incident was found to be inefficient. During a review of the facility file it was noted that incident reports are completed when submitted, however they continue to be submitted late. In 2023 so far, four out of 16 have been submitted more than forty-eight hours after the incident occurred.
      • 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 Licensee's system to ensure that self-monitoring is completed is ineffective. During the inspection, it was noted that there have been no audits completed since January 2023. Prior to this, audits were being completed but when non-compliance was found it was observed that no follow up was being completed to address the non-compliance.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R4.6 - Are facility records current and complete?
      • Observation(s): The Licensee does not have a system in place to ensure that a record of menu substitutions is kept. It was observed that notes are made when a substitution occurs, however records are not maintained.
      • R4.6C - Retain food services records of menus and menu substitutions; 87(b)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The Licensee's system to ensure that hygiene is maintained as pertaining to personal items is ineffective. During the inspection, it was noted that an unlabeled hairbrush and deodorant were in a tub room that is shared by persons in care. The items were removed during the inspection when the manager was notified.
      • 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 Licensee's system to ensure hazardous materials are not accessible to persons in care is ineffective. During the inspection, it was noted that scissors and cans of hairspray were present in a room that was noted to be left open with no staff nearby. The door has a sign indicating that it must be kept closed at all times. This was corrected during the inspection after the Licensing Officer brought it to the attention of a staff member. During the inspection, it was noted that there is no system in place to ensure that the weekly menu is posted in a prominent place. The Licensee's system to ensure that all treatment creams are safely and securely stored was found to be ineffective. During the inspection, it was observed that a treatment cream was left unlocked in a person in care's bedroom cabinet. This is the third consecutive time this has been found out of compliance.
      • 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)
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee does not have a system in place to ensure that ongoing tray service is reassessed every thirty days. During the inspection, it was noted that one person in care has an order allowing for ongoing room tray service, however, this is not reassessed as required.
      • 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 Licensee's system to ensure that wound care plans are being followed was found to be ineffective. During the inspection, it was observed that wound care treatment was not being provided daily as ordered in the wound care plan. It was also noted that the care plan of a different person in care was updated to include a falls mat but this information was not reflected on the My Day which was posted to guide the employees who provide direct care.
      • 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
  6. Routine Inspection

    7 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): PRN charting observed during this inspection at times did not indicate the reason or result of the medication. Treatment administration records observed during this inspection were sporadically charted.
      • 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): Restraint charting observed at 12:00pm had not been completed for the morning checks, and it appears charting for the whole shift is often being charted at the end of the shift, ensure charting is completed closer to the completion of the restraint checks for more accuracy in documentation.
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Employee performance reviews are overdue, please inform on what systems will be put in place to ensure overdue evaluations are caught up, and kept up to date moving forward. There is no system in place to ensure an employee on site at all times has valid first aid/CPR. This was noted during the last routine inspection at the site.
      • 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)
      • R3.1O - 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)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Daily snacks are being offered, however the snacks available are not included in the posted menu. Ensure daily snacks are posted along with or in the posted menu and are kept for review if required. Substitutions to the posted menu have not been documented for review at a later date if required.
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
      • R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): During the physical inspection of the facility, a treatment cream was located unlocked in a person in care room. The cream was locked at the time of inspection. This contravention was also noted during the last routine inspection at the site.
      • 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): Family and resident council meetings have not occurred since prior to COVID 19 pandemic. Inform licensing on how the meetings will be re-established.
      • R10.2R - 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)
    • 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): Some baths missed on a recent shift, some were made up over the next day, several were not made up. Inform licensing on what systems are in place to ensure missed baths are made up as soon as possible.
      • 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
  7. Routine Inspection

    4 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): There is no system in place to ensure that the monitoring of the persons in care while in restraints is consistently documented.
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): There is no system in place to monitor the employees who are required to hold a valid First Aid Certificate to ensure that they have one in place.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): There is no system in place to ensure the safe storage for prescription treatment cream. During the physical inspection a treatment creams was located unlocked in a person in care's bathroom. This was removed and stored safely during the inspection.
      • 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): The system in place for persons in care to have in their possession written identification when they temporarily leave the facility is ineffective. Management discussed the system in place, however the business cards were not stored where they stated they were, nor could a system be identified for how persons in care and their representatives are aware of the process.
      • R10.2L - Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56( 1 ) ( 2 )
  8. Monitoring

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): September 08, 2017 - There is no process to ensure the compliance with the display of the manager's name in a prominent, and acceptable manner. The facility's new licence is located in a prominent area, however the manager's name is not posted.
      • 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): September 08, 2017 - UNRESOLVED - There is no process in place to ensure the facility's emergency plans are updated with a change in the facility. The facility downgraded an emergency exit due to the stairs being narrow and unstable. The facility's emergency plan that is posted shows green arrows for all exit doors that lead out of the building. It does not identify the safe emergency exits from all exit doors. September 08, 2017 - The facility's system for ensuring that employees follow the facility's policies and procedures is ineffective. During the physical inspection of the facility LO found two unlocked cupboards in person in care's rooms. The cupboards contained prescription creams, and wound care treatments.
      • R2.1H - Update emergency plans if there is any change in the facility; 51 ( 2 )
      • 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): September 08, 2017 - UNRESOLVED - The facility's process for self monitoring of the outside physical environment is ineffective. The water feature in the outside court yard splashes water on the surrounding pavement, and algae forms leaving a slippery wet surface that poses as a falls risk to persons in care.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
  9. Monitoring

    8 infractions

    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Aug 09, 2016 - The facility's process of TB screening for persons in care is ineffective. LO reviewed a new admission chart for a person in care and was unable to locate a TB screen.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 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): July 20, 2016 - The facility's process for updating their emergency plans is ineffective. The facility has upgraded an exit to an emergency exit with a ramp and downgraded a emergency exit to just an exit. However the emergency plan posted does not reflect the change in the exits.
      • Update emergency plans if there is any change in the facility; 51 ( 2 )
    • 4.6 Are facility records current and complete?
      • Observation(s): July 20, 2016 - The facility does not currently have a process in place for the monitoring of food services and nutrition care. LO spoke to the dietary supervisor who stated that the facility is currently in the process of developing a system for the monitoring of food services and nutrition care.
      • Retain the results of monitoring of food services and nutrition care; 87(c)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): July 20, 2016 - The facility's process for self monitoring the safe storage of food is ineffective. LO observed a bowl of cereal stored on top of a microwave in the dining room on Bernard. The food was not covered or dated and appeared to contain milk. The fridge on Bernard was found to have unlabelled and undated food in a lower drawer. These items were discussed with the dietary supervisor at the time of the inspection.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): July 20, 2016 - The facility's process for self monitoring the physical environment is ineffective. LO slipped on algae forming around the rock fountain outside in the court yard that persons in care utilize. LO discovered a large tin outside the back of the facility with two chairs on either side. The tin contained a large amount of cigarette butts indicating staff are smoking on facility premises. LO found a medication cart with the handle unlocked, unattended in a hallway that leads to persons in care's rooms. A person in care who self administers their inhalers does not have a safe and secure storage area for their medication.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Ensure that no one other than a person in care smokes while on the premises; 23(a)
      • Ensure all medications are safely and securely stored; 69( 3 )(a)
      • Provide a safe and secure storage area for self-administered medications; 69( 3 )(b)(i)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): July 20, 2016 - The facility's process for self monitoring the safe storage of medications is ineffective. LO found a medication cart with the handle unlocked, unattended in a hallway that leads to persons in care's rooms. A Licensee must ensure that (a) all medications in the community care facility are safely and securely stored and (b) in the case of a person in care whose short term care plan provides for the person in care to self-administer medication, the person in care (i) has a safe and secure storage area for medication and (ii) stores all medications in the storage area described in subparagraph (i); 69 (3)(a)(b)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): July 20, 2016 - The facility does not currently have a process in place to ensure that all persons in care who leave the facility temporarily carry facility identification.
      • Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56( 1 ) ( 2 )
    • 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): July 20, 2016 - The facility currently does not have a process to ensure care plans are in place to address persons in care who self medicate. An individual who self medicates did not have a care plan in place for self medicating.
      • Care plans must include a plan to address medication, including self-medication; 81( 3 )(a)(i)

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