Elizabeth Lake
113 19 St S Cranbrook BC V1C 0A1 · Residential Care - Licensing
3 inspections
- Routine Inspection
5 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): R4.2 - The medication administration records reviewed contained multiple missing signatures for regularly scheduled medications. Failure to ensure complete medication administration records, including required staff signatures, poses a potential risk to the health and safety of persons in care by limiting the licensee's ability to confirm safe and accurate medication administration practices in accordance with established policies and regulatory requirements. Submit by February 4, 2026, a written plan outlining how the contravention related to ensuring that the medication administration record shows the date, amount and time at which the medication was administered, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 78(2)(b) of the Residential Care Regulation, ensuring sustained compliance moving forward.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): R1.1 - During the review of internal monitoring documents, the audits were signed off as compliant; however, further review identified gaps that had not been addressed prior to sign off. This indicates a deficiency in the thoroughness of the review conducted during the auditing process. Inconsistent or incomplete documentation reduces the licensee's ability to demonstrate compliance with required standards. This may result in unmitigated risks, reduced oversight of critical processes, and potential failure to identify or address issues in a timely manner. Continued gaps undermine the reliability of oversight mechanisms and may lead to regulatory non-compliance. Submit by February 4, 2026, a written plan outlining how the contravention related to ensuring that the physical environment and the care and services provided are regularly monitored, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 61of the Residential Care Regulation, ensuring sustained compliance moving forward.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): R4.1 - During a review of person in care's records the monthly weights are noted to be inconsistently documented. The records do not currently 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. Missing documentation can delay timely assessment and intervention, potentially compromising the safety and well being of the person in care. Submit by February 4, 2026, a written plan outlining how the contravention related to ensuring that each person in care has their weight taken and recorded monthly, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 83(4)(a)(c) of the Residential Care Regulation, ensuring sustained compliance moving forward.
- R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): R7.1 - A review of the facility's fire extinguishers and emergency lighting revealed that there is no documented evidence of current inspections. The licensee reported concerns regarding the performance of the contracted inspection company and advised that they are currently following up to address the issue. The licensee confirmed that arrangements are being made to ensure all required inspections are completed within the month of January. The absence of documented inspections for fire extinguishers and emergency lighting may delay the identification of equipment that is non-functional or past service life, potentially impacting the facility's ability to respond effectively in an emergency. Submit by February 4, 2026, a written plan outlining how the contravention related to ensuring that emergency exits, equipment, and monitoring and signaling devices are inspected on a regular basis, amount and time at which the medication was administered, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 22(3) of the Residential Care Regulation, ensuring sustained compliance moving forward.
- R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
- 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): R10.3 - During the review and through discussion with the licensee, it was identified that the behavioral care plans do not include all the necessary interventions to direct staff in supporting the person in relation to their identified behaviors. Without complete and clearly documented interventions, staff may respond inconsistently to behavioral incidents. This could increase the risk of ineffective behavioral management, potential escalation of behaviors, and reduced safety and well-being for the person and the others in the care environment. Submit by February 4, 2026, a written plan outlining how the contravention related to ensuring that care plans include a plan to address behavioral interventions, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 81(3)(a)(ii) of the Residential Care Regulation, ensuring sustained compliance moving forward.
- R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection Follow-up
2 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): R1.1W - Records reviewed, including documentation for safety checks, room and bag checks, internal incident reports, and incident reports submitted to Licensing, indicate that the licensee did not implement the system for monitoring as outlined in a Health and Safety Plan submitted and accepted by Licensing on September 19th, 2025. The absence of implementing a monitoring system compromises the licensee's ability to ensure ongoing compliance with the health and safety requirements, and places persons in care at potential risk of harm. The licensee is required to submit a revised health and safety plan no later than 12:00pm on October 6, 2025. The plan must outline the monitoring system that will be immediately implemented to ensure oversight of the health and safety plan, and ongoing compliance with Section 61 of the Residential Care Regulation.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- 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): R10.3M - A review of care plans, safety check documentation and cell phone records indicated that safety checks were not completed in accordance with the requirements outlined in the care plan. A health and safety plan was submitted and accepted by Licensing on September 19, 2025, to ensure safety checks were completed as outlined in care plans. This plan was to remain in place until such a time that Licensing approved a modification or removal of the plan. The September 19th, 2025, health and safety plan directed the implementation of safety monitoring and room and bag checks; however, a review of the documentation identified that these checks were not completed in accordance with the care plan, and there was no evidence of monitoring to ensure compliance. Failure to provide care as outlined in the care plan creates a risk that health, safety and personal needs of persons in care may not be consistently met. The licensee is required to submit a revised health and safety plan no later than 12:00pm on October 6, 2025. The revised plan must outline the monitoring system that will be implemented to ensure effective oversight the health and safety plan. This includes oversight of the care and services provided, as well as the accuracy and completeness of the revised documentation records.
- 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
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection
5 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): R1.1W - Records reviewed, including facility records, person in care records, medication administration records, and plans submitted to Licensing, indicate that the licensee does not have a system in place to regularly monitor the physical environment or the care and services provided, as demonstrated by the contraventions outlined in this report. The lack of a monitoring system compromises the licensee's ability to ensure ongoing compliance with health and safety requirements, place persons in care at potential risk of harm. Submit by October 8, 2025, a written plan outlining how the contravention related to ensuring that the monitoring of the physical environment and the care and services being provided has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 61 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- 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): R3.1AA - A review of medication administration records identified that employees are not consistently documenting the effectiveness of as needed medications (PRN), as required. Failure to document PRN effectiveness of as needed medications creates a risk that the medication's impact on the person in care will not be evaluated, which may result in unmet care needs or unresolved symptoms. Submit by October 8, 2025, a written plan outlining how the contravention related to ensuring that employees comply with the policies and procedures of the medication safety and advisory committee has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 68(4) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): R4.1S - A review of person in care's records indicated that a newly admitted individual did not have a short term care plan in place. Without a short term care plan, there is a risk that staff may not have the necessary guidance to provide consistent and appropriate care for the new admission, which may compromise the person's safety and well being. Submit by October 8, 2025, a written plan outlining how the contravention related to ensuring that a short care plan is developed on admission, including anything that must be recorded in a care plan has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 80(2) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- R4.1S - Ensure a short term care plan developed on admission includes anything that must be recorded in a care plan; 80 ( 2 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): R7.1C - Daily records indicated that the water temperature exceeded 49 degrees Celsius. During the inspection the licensee adjusted the temperature on the hot water tank. The licensee confirmed before the end of the day that the water temperature was below 49 degrees Celsius. If water temperature exceeds the required limit, there is a risk of burns or scalds to persons in care. Submit by October 8, 2025, a written plan outlining how the contravention related to ensuring that the water accessible to persons in care does not exceed 49 degrees Celsius has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 17 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward. R7.1AK - Laundry detergent and fabric softener were observed left on top of the washing machine, making them accessible to persons in care when not in use. The detergent and fabric softener were removed and placed in a locked cupboard during the inspection. Failure to secure hazardous cleaning products increases the risk of serious harm to persons in care. Submit by October 8, 2025, a written plan outlining how the contravention related to ensuring secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 35(1)(c) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward. R7.1AR - The key to the medication cabinet was found in an unlocked kitchen drawer, making it accessible to persons in care. The key was removed during the inspection and placed in a locked office only accessible to employees. Accessible medication cabinet keys create risk that persons in care could gain unauthorized access to medications. Submit by October 8, 2025, a written plan outlining how the contravention related to ensuring that all medications are safely and securely stored has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 69(3)(a) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- 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)
- R7.1AR - 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): R10.3M - A review of persons in care care plans indicated that safety checks were not completed in accordance with the requirements outlined in the care plan. A health and safety plan was submitted and accepted by Licensing on September 19, 2025, to ensure safety checks are completed as outlined in care plans. This plan will remain in place until such a time that Licensing approves a modification or removal of the plan. Failure to provide care as outlined in the care plan creates a risk that health, safety, and personal needs of persons in care may not be consistently met. Submit by October 8, 2025, a written plan outlining how the contravention related to ensuring that the care and supervision of a person in care is consistent with the terms and conditions of the care plan has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 82 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- 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
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?