Fischer Place
555 Cedar Ave 100 Mile House BC V0K 2E1 · Residential Care - Licensing
13 inspections
- Routine Inspection
6 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Incident reports for some reportable incidents have not been submitted to Licensing Direct. All reportable incidents (Residential Care Regulation - Schedule D) are required to be immediately submitted to Licensing to allow for review and follow-up when needed. Submit a corrective action plan by March 9, 2026, which details what systems will be put in place to ensure all reportable incidents are submitted to Licensing Direct immediately.
- R4.5G - 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): This is an ongoing contravention. During this inspection it was observed the last routine inspection report for the facility was not posted. The most recent routine inspection report must be posted to allow persons in care and visitors to review the inspection report. Submit a corrective action plan by March 9, 2026, indicating what systems will be put in place to ensure the most recent routine inspection report is posted.
- R1.1O - Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): This is an ongoing contravention. Performance evaluations are overdue for most facility staff. Regular performance reviews are required to ensure staff are completing their job descriptions to ensure the health, safety, care and dignity of persons in care. Submit a corrective action plan by March 9, 2026, indicating what systems will be put in place to complete overdue performance evaluations and keep them on schedule moving forward.
- 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)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): A chart was reviewed for a person in care admitted over two months ago, there was a short term care plan in place, but no My Day or Long Term Care plan in place yet. A Long Term Care Plan is required for any person in care over 30 days to ensure they receive personalized, safe and coordinated care. Submit a plan of action by March 9, 2026, detailing what systems will be put in place to ensure Long Term Care plans are in place for all persons in care within 30 days of admission.
- R4.1T - Ensure a care plan is developed within 30 days for persons in care admitted for more than 30 days; 81.1; Director of Licensing Standards of Practice: Advance Directives and Care Plans
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Several areas (recreation storage, utility room, housekeeping room, staff room) observed with either unlocked doors or unlocked cabinets which contained potentially hazardous materials (scissors, cleaners, staff personal belongings). Doors were closed/locked during inspection. All potentially hazardous materials/areas must be kept inaccessible to persons in care to help prevent illness/injury. Submit a corrective action plan by March 9, 2026, which details what systems will be put in place to ensure all potentially hazardous materials will be kept inaccessible 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)
- R10.3 - 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 care plan for a persons in care (PIC) who can leave the site independently did not include details of the leaves or information on what steps to take if the PIC did not return to by the expected time. Care plans for PIC who can leave the facility independently must include specific details to support the safe outing and return to the facility. Submit a corrective action plan by March 9, 2026, which details what systems will be put in place to ensure all care plans for PIC who can leave the facility independently will be completed and updated as needed.
- 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Substantiated complaint
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): Licensing received a complaint indicating a care conference was completed without an invite to the representative for the person in care. Follow-up into this concern showed an invite was not sent to the representative and the care conference was completed without them. During the time since Licensing received this complaint on October 19, 2025, a new care conference has been completed that involved the representative for the person in care. The involvement of the person in care if able, and the representative for the person in care during Interdisciplinary Care Conferences is necessary, to help work within the team to develop and adjust the care plan to address the person in care's needs and help achieve their goals. Submit a corrective action plan by December 5, 2025, which details what systems will be put in place to ensure representatives for persons in care will be given the opportunity to be involved in care planning and care conferences.
- 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)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Substantiated complaint
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): Licensing Direct received a complaint indicating Fischer Place had not responded to concerns brought forward appropriately or in a timely manner. A Licensee must follow-up on all complaints and disputes fairly and promptly as per Residential Care Regulation (RCR) 60. Fischer Place received concerns from the complainant regarding the facility's infection control and sign in and out procedures in March and April of 2025. Clear, effective and prompt responses to the concerns were not provided by Fischer Place prior to Licensing Direct being notified on May 15, 2025. Substantiated. Submit a corrective action plan by August 29, 2025, indicating what systems will be put in place to ensure all complaints received by Fischer Place will be responded to fairly and promptly. Licensing Direct received a complaint indicating sign in and out procedures for persons in care, when they leave the facility with family and or a representative were not being completed/monitored consistently. Ensure policies are implemented by employees as per RCR section 85(1)(d). If persons in care are not signed in and out when they are leaving the building, it may cause confusion/delays in the event of an emergency. A review of recent sign in and out charting as well as discussions with staff and site leadership showed charting was inconsistently completed. Substantiated. Submit a corrective action plan by August 29, 2025, indicating what systems will be put in place to ensure employees are implementing the facility in an out procedure. Licensing Direct received a complaint indicating site infection control processes were being implemented inconsistently, as some persons in care were able to have personal furniture in their room with a fabric/cloth cover, while others were told on admission that all furniture must have a wipeable surface which can easily be cleaned/disinfected. Infection control policies must be followed to help ensure the health, safety, care and dignity of persons in care. A review of the documentation provided, as well as conversation with facility staff and leadership has shown the process of not allowing fabric/cloth furniture in person in care bedrooms has been implemented inconsistently. Substantiated. Submit a corrective action plan by August 29, 2025, which indicates what systems will be put in place to ensure facility infection control policies are being implemented.
- R2.1L - Respond to all complaints, concerns, disputes promptly. 60(c)
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- 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): Licensing Direct received a complaint which indicated changes had been made to a care plan for a person in care without notification or involvement of the representative. Care plans should be developed to the extent reasonably practical with the participation of the person in care or their representative as per RCR section 81(2). A review of the care plan, the person in care's chart and follow-up with site leadership has shown changes were made to the behavioural care plan without notification or involvement of the person in care or their representative. Substantiated. Submit a corrective action plan by August 29, 2025, which indicates what systems will be put in place to ensure all care plans are developed and updated with participation of the person in care or their representative when possible.
- 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)
- 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?
- Routine Inspection
4 infractions
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): This is an ongoing contravention. Restraint charting observed during this inspection was found inconsistent, and did not always reflect the frequency required in the restraint care plan. Restraint observation and charting is required to ensure person in care (PIC) safety while utilizing a restraint. Submit a corrective action plan by August 6, 2025, which indicates what systems will be put in place to ensure restraint monitoring is completed and charted as per restraint care plans.
- 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): During this inspection it was observed the last routine inspection report for the facility was not posted. The most recent routine inspection report must be posted to allow persons in care and visitors to review the inspection report. Submit a corrective action plan by August 6, 2025, indicating what systems will be put in place to ensure the most recent routine inspection report is posted.
- R1.1O - Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
- 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): Current consent for restraint care plans, signed by the person in care (PIC) representative and Medical Practitioner was not available in some charts reviewed. Up to date signed restraint care plans are needed to ensure restraints are being implemented in accordance with Medical Practitioner and PIC representative agreement. Submit a corrective action plan by August 6, 2025, detailing what systems will be put in place to ensure restraint care plans are signed off by PIC representative and Medical Practitioner at least annually.
- 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): This is an ongoing contravention. Performance evaluations are overdue for most facility staff. Regular performance reviews are required to ensure staff are completing their job descriptions to ensure the health, safety, care and dignity of persons in care. Submit a corrective action plan by August 6, 2025, indicating what systems will be put in place to complete overdue performance evaluations and keep them on schedule moving forward,
- 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)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Routine Inspection
5 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): A review of facility incident reports for the last year was completed prior to this inspection, reports at times are submitted with missing information on the events leading up to the incident as well as immediate actions taken after the incident. After discussion during the inspection and a review of some charts in appears some incidents are being submitted through the Patient Safety Learning System, but are not being submitted to Licensing through the incident reporting portal. Please review/update site incident reporting processes to ensure reportable incidents are being submitted to Licensing through the portal and include required details of the incident/follow-up.
- 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)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Restraint charting observed during this inspection was inconsistent, and did not reflect the frequency indicated in the restraint care plan(s).
- 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)
- 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): Please update facility dispute resolution policy, to include processes for documenting complaints received, as well as the steps taken by the facility to resolve the concern. Care conferences have not been occurring since March 2024, please inform on what processes will be put in place to allow for a six week care conference for new admissions, as well as yearly care conferences for all other persons in care.
- R2.1J - Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(a)
- 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): Performance evaluations are overdue for most staff, this contravention is ongoing, as it was also noted during the last routine inspection. Please submit a plan on how overdue employee evaluations will be completed, and kept on schedule moving forward.
- 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Resident laundry room, housekeeping room and servery room doors were all observed unlocked during this inspection with no staff immediately present, all of these rooms contained materials which could potentially be hazardous to vulnerable persons in care. Inform Licensing on what systems are in place to ensure potentially hazardous materials/areas are kept inaccessible 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
3 infractions
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Employee performance evaluations are overdue, this contravention was noted during the last routine inspection in October 2022 and was found unresolved during this visit. Systems have started to be put in place to commence overdue reviews, please give a detailed response that includes specific targets for completion of reviews moving forward.
- 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Cigarette butts observed in a small container just outside the door leading to an outdoor activity area for persons in care. No persons in care smoke in this area of the building. The Clean Utility room and a Storage Room door were observed unlocked during this inspection with no staff present, both rooms contained items which could potentially be hazardous to person in care. (Disinfectant, staff backpacks).
- R7.1M - Ensure that no one other than a person in care engages in a restricted activity while on the premises of the facility; 23(2)(a).
- 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): Wound care charting for one person in care observed to be be not reflective of the wound care plan in place.
- 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
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Routine Inspection
5 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): There is currently no self-monitoring system in place.
- 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): There is currently no system in place to schedule and conduct regular performance appraisals of staff.
- 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)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): Written consent to call a medical or nurse practitioner or ambulance in case of accident or illness could not be located for persons in care. This is required by RCR Section 78(3)(a).
- R4.1I - 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)
- R4.6 - Are facility records current and complete?
- Observation(s): A record of all complaints made, concerns expressed, and responses to them is not currently in place.
- R4.6F - Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Door lock to kitchen area/servery not functioning properly at time of inspection Lock to secure area containing person in care records not functioning properly at time of inspection. Door being left open as a result. Records must be stored securely to prevent unauthorized access.
- R7.1AJ - Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection
3 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): LO Vermeulen reviewed medication administration records at random. Some records do not consistently indicate that medications were administered as required. PRN administration records have not consistently included the results of the PRN, as required. Please ensure record keeping meets the requirements of RCR 78(2)(b) and that appropriate monitoring of this record keeping is in place. These issues of non-compliance were identified during 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): LO Vermeulen reviewed restraint record keeping used for a PIC who currently has a restraint care plan in place. The monitoring record did not include the duration of the restraint being used. Please ensure record keeping meets the requirements of RCR 84(d) and that appropriate monitoring of this record keeping is in place.
- 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): LO Vermeulen observed doors leading to areas meant to be inaccessible to persons in care unlocked at time of inspection. Please ensure persons in care do not have access at any time to hazardous areas or products in order to prevent risk of injury.
- 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)
- R7.1AM - Ensure that laundry facilities if not used by persons in care, cannot be accessed by persons in care; 35( 2 )(b)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
4 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): LO Vermeulen reviewed medication administration records at random. Some records do not consistently indicate that medications were administered as required. PRN administration records have not been consistently filled out to include the result of the PRN. This was identified as a contravention during the previous two inspections.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- 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): Recreation and leisure plans have not been transferred over to the care plan accessible by care staff. In speaking with recreation staff on site at time of inspection, it appears that recreation and leisure assessments are completed but not always accessible by care staff.
- 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.
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): LO Vermeulen and the facility manager discussed self-monitoring of the physical environment and the care and services provided. The physical environment is currently being inspected on a regular basis by the JOHS committee. A system of regularly monitoring the care and services provided to ensure that the requirements of the Act and Residential Care Regulation are being met is required.
- 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): LO Vermeulen reviewed care plans at random. Recreation and leisure plans have not been transferred over to the care plan accessible by care staff. In speaking with recreation staff on site at time of inspection, it appears that recreation and leisure assessments are completed but not always accessible by care staff. This was identified as a contravention during the previous two inspections.
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
5 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Some medication administration records reviewed did not include the charting of the result of PRN medications. Please respond with what systems and audits will be put in place regarding PRN documentation.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Ensure every restraint care plan includes consents for the restraint, the type and duration of the restraint, how often the restraint requires observation and how/where the observation of the restraint is to be charted. Also include in your response what systems are in in place to audit the restraint documentation.
- R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Regular performance evaluations are overdue for facility care staff, inform Licensing on the plan to catch-up on overdue staff performance evaluations. Facility has a plan to have all LPN's and recreation staff to hold first aid/CPR certificates, several have expired at this time. Inform Licensing on what systems and audits are in place to ensure PIC's have access to staff with valid first aid/CPR at all times.
- 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)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): The facility currently does not have a resident and family council established, ensure you provide at least an annual opportunity for PIC's and their representatives to establish councils or similar organizations to represent the interests of the PIC's.
- 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 recreation plans for residents who have been in care for more than 30 days have not been completed. Ensure all overdue recreation plans are completed and a system/audit is in place to to have all future recreation plans in place within 30 days of admission. This infraction was noted during the last Licensing visit and noted as unresolved during this visit.
- R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
5 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): Recreation plans for several residents who have been in care more than 30 days have not been completed. Ensure all recreation plans which are overdue are completed and a system is developed to make sure all new admissions have a completed recreation plan in place within the first 30 days after admission to the facility. A short term care plan observed did not include specifics in the oral care plan, ensure the plan is updated, also please review short term care plan procedures to ensure all required information is included, please include what auditing systems are in place regarding short term care plans.
- 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.
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): A short term care plan observed did not include specifics in the oral care plan, ensure the plan is updated, also please review short term care plan procedures to ensure all required information is included, please include what auditing systems are in place regarding short term care plans.
- R4.1O - 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 )
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): The facility has not had a recent Medication Safety Advisory Meeting, ensure a meeting is scheduled and on-going MSAC meetings are scheduled to review facility medication storage, documentation and administration procedures.
- 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)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): A process for ensuring all PIC's who may leave the facility without notifying staff have identification is not currently in place. Please develop a system including auditing measures that ensures all PIC's who are a risk for wandering have identification that includes the PIC's name, facility name and emergency contact information.
- 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)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): Recreation plans for several residents who have been in care more than 30 days have not been completed. Ensure all recreation plans which are overdue are completed and a system is developed to make sure all new admissions have a completed recreation plan in place within the first 30 days after admission to the facility.
- R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
- 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?
- Monitoring
4 infractions
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): PRN documentation not consistently charted to include the reason and result of medication.
- Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- 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): All staff receive training regarding emergency procedures, ensure this training includes information regarding changing duties on afternoon and night shifts when staffing levels are different than on day shift.
- Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Broken latch on servery door, this allowed PIC to be in servery area unattended when LO first entered Fischer Place. Servery area contained cleaners which should not be accessible to PIC's, this area should also only be accessible to staff due to food safe issues. Cleaners found accessible to PIC's in servery area and tub room at the time of this inspection, ensure all potentially hazardous materials are stored in an area that is inaccessible to PIC's.
- Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): Some resident days reviewed had faded information or information which was difficult to read, ensure the documents are updated. Sticky notes observed in several care binders and resident days, ensure important information is added to documents rather than using sticky noted which could bee misplaced.
- Review and modify a care plan with the person in care's participation to the extent reasonably practical; 81( 4 )(c)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
6 infractions
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Some MAR's reviewed during this inspection had missed charting of medications. PRN documentation regarding reason and result of PRN was not always documented.
- Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78(2)(b)
- 4.5 Are incidents and notifications reported and records retained as required?
- Observation(s): Licensing has been receiving incident reports from Fisher Place, however some reports have been missing required information (notification of all representatives) and have been received late. Ensure Incident reporting procedures are reviewed. Please indicate on all IR forms which section of the building the incident occurred (Fisher Place 14 beds Licensed facility or Millsite Lodge hospital Act facility).
- Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77(2)(c)
- 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Karen indicated she has a self monitoring document in place but it has not been completed recently. Ensure self monitoring occurs regularly and is documented in a format that includes any changes made and also includes dates.
- Regularly monitor the physical environment and the care and services provided; 61
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Facility Manager indicated the goal of performance evaluations every three years for staff is behind schedule. Please submit a plan as to how the facility is moving towards having all performance evaluations up to date. Facility Manager indicates there is a staff qualification checklist that is being developed to document staff qualifications required under RCR 37, but the document was not available at the time of this inspection for review by Licensing.
- 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)
- Keep in the case of employees, all records required under section 37 (1)[character and skill requirements] for the entire time that the subject of the records is an employee; 92(3)(a)
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): Height and weight on admission, as well as hair colour and eye colour which can be used to identify a PIC in an emergency not recorded for several PIC records reviewed.
- Record the height and weight of each person in care on admission; 49 (2)
- 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)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Handrails in one portion of hallway were blocked by a mat and a piece of equipment which were stored leaning against the wall, handrails not available on the other side of hallway in this area. Ensure handrails on at least one side of hallway are kept clear to allow for resident use when required. Servery doors found unlatched leading into kitchen/food service area, ensure doors are properly latched when staff not present to help prevent persons other than staff from entering food prep area.
- Maintain all rooms and common areas in a safe and clean condition; 22(1)(c)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?