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EHN Edgewood Rockies

8350 Holmes Rd Fort Steele BC V0B 1N0 · Residential Care - Licensing

5 inspections

  1. Routine Inspection

    1 infraction

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): R5.1C - The weekly menu for the morning, noon and evening meal does not contain at least 3 food groups as described in Canada's Food Guide for each meal. R5.1D - The current weeks menu does not include at least 2 nutritious snacks each containing at least 2 food groups as per the Canada Food Guide. Submit by December 23, 2025, a written plan outlining how the contravention related to ensuring that weekly menus contain the required meal and snack information, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 62(2)(a)(b) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R5.1C - Provide for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups described in Canada's Food Guide; 62( 2 )(a)
      • 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)
  2. Routine Inspection

    7 infractions

    • RB1.26 - Is a short term care plan developed on admission to guide staff in protecting and promoting the health and safety of the person in care?
      • Observation(s): The Licensing Officer reviewed person in care's records and engaged in discussions with employees regarding care plans. There was no documented evidence that the licensee has a system to ensure a care plan is developed for all persons upon admission.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): R1.1 W requires the licensee to regularly monitor the physical environment, and the care and services provided. During the inspection, the Licensing Officer reviewed the compliance plan submitted to Licensing following the April 2024 inspection, as well as the plans submitted for two approved exemptions in 2024. The plans appeared to have been implemented, however, there was no documented evidence of review, or monitoring to ensure compliance or effectiveness of the plans. The Licensing Officer also reviewed person in care's records, facility records, and inspected the physical space. The results of this review resulting in non-compliance is captured within this report. This is an ongoing contravention from the April 2024 inspection.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): R2.1C requires that prior to admission the licensee advise how the person, their parent or representative may express concerns or make complaints to licensing. The Licensing Officer reviewed admission documents, and information that is provided to persons in care prior to admission. The documented evidence provided information on how to contact the Patient Care and Quality Office, but did not include information on how to contact Licensing as per the legislative requirements.
      • R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): R4.1R requires the licensee to ensure a short-term care plan is developed on admission that guides caregivers in protecting and promoting the health and safety of the person in care. The Licensing Officer reviewed person in care's records and engaged in discussions with employees regarding care plans. There was no documented evidence that the licensee has a system to ensure a care plan is developed for all persons upon admission.
      • R4.1R - Ensure a short term care plan is developed on admission that guides caregivers in protecting and promoting the health and safety of the person in care; 80 ( 1 )
    • R4.6 - Are facility records current and complete?
      • Observation(s): R4.6T requires the licensee to retain records of complaints for at least 2 years. The Licensing Officer reviewed records of complaints submitted by the licensee. The licensee provided records of complaints for the past 8 months, informing Licensing that previous complaints records were not available.
      • R4.6T - Retain records of complaints for at least 2 years; 92 ( 6 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): R7.1AK requires the licensee to provide appropriately equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials. During the inspection of the physical facility, an unlabeled bottle was accessible to persons in care in the laundry room. This bottle was immediately removed by the licensee during the inspection. The laundry room also contained cleaning agents, and laundry products identified as 'harmful if swallowed', and to contact poison control center if ingested. The licensee does not currently have a system in place to ensure safe storage of cleaning agents and chemical products in the laundry room accessible to persons in care.
      • 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): R10.2A requires the licensee to monitor the health and safety of each person in care regularly to determine if their needs continue to be met. The Licensing Officer reviewed monitoring documents as outlined in health and safety plans for 2 approved exemptions. The documents were noted to be inconsistent in completion with no evidence of ongoing monitoring or follow up to ensure compliance. It was also identified that the monitoring documents were not initiated upon admission. The record of monitoring indicated that monitoring was not completed for the initial 3-day period, and 19-day period in relation to the approved exemption plans.
      • 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

    1 infraction

    • 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): Allegation - The Licensee is in non-compliance with the Residential Care Regulation (RCR) Section 85(1)(d) as it pertains to employees implementing policies related to issuing refunds. Finding - SUBSTANTIATED. During the investigation, the refund policy was reviewed, in combination with email records, and an interview with the employee issuing refunds. The policy states that a refund is issued to the Payor; however, the refund was noted to be issued to the person in care. The Licensee corrected the non-compliance prior to this investigation, after they received notice of the error from the person in care's family.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  4. Routine Inspection

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system to ensure licensing is immediately notified when a person in care is involved in a reportable incident is ineffective. During a review of minor incidents, and through discussions with on site staff, it was identified that a reportable incident had not been reported as per the requirements of the Residential Care Regulation. This contravention is ongoing from the April 21, 2023 inspection.
      • R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): The system to ensure laundry facilities have a slip resistant floor surface when used by persons in care is ineffective. During the inspection a laundry room utilized by persons in care did not have a slip resistant floor surface.
      • R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The system to regularly monitor the physical environment and the care and services provided is ineffective. During the inspection the licensee was unaware that attendance records were incomplete, there is no clearly identified system for monitoring care and services provided. This is also evidenced by the number of contraventions identified within this inspection report.
      • 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 provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care was ineffective. It was identified during the inspection that the licensee does not currently have all written policies related to guiding employees in all matters related to care and supervision of persons in care. The system to ensure all policies and procedures are available to employees at all times, and to licensing and persons in care and the parent/representative on request is ineffective. The licensee was unable to provide policies to Licensing when requested during this investigation.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1R - Make all policies and procedures available to employees at all times, to licensing, a person in care and the parent/representative on request; 85( 1 )( c) (i)(ii)(ii.1)(iii)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system to ensure secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials is ineffective. During the inspection of one cabin, cleaning agents were identified on an open shelf, in an unlocked laundry room that is accessible by persons in care.
      • 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)
  5. Routine Inspection

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): In review of facility records it was noted that incidents were not reported to Licensing as required. This Licensing Officer provided education to the Licensee on Incident Reporting and Schedule D of the Residential Care Regulation. In addition, self-monitoring of non-reportable incidents was discussed.
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): It was identified during the inspection that there is currently no system in place to monitor fridge and freezer temperatures in the detox building to ensure safe storage of food.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): It was noted during this inspection that the medication safety and advisory committee review was overdue.
      • R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)