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F.W. Green Memorial Home

1700 4th St S Cranbrook BC V1C 6E1 · Residential Care - Licensing

19 inspections

  1. Routine Inspection

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): R4.5G - A review of a person in care’s focus notes identifies a recent incident of missing/wandering. A review of incident reports submitted to Licensing confirms that this reportable incident was not reported to Licensing in accordance with legislative requirements. Failure to report incidents as required may limit regulatory awareness and oversight, and may delay the identification of trends or concerns that support compliance and the ongoing health and safety of persons in care. This is a re-occurring contravention from the November 2022, March 2023, May 2024, August 2024 and September 2025 inspections. As a result of the re-occurring contravention, submit by May 20, 2026, a new and different written plan outlining how the contravention related to ensuring Licensing is immediately notified in the form and manner required of all reportable incidents has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 77(2)(c) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward. The licensee must also report the missing/wandering incident to Licensing, including all required details.
      • 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)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): R10.4P - A review of care plans identifies that multiple persons in care who are occupying short‑stay and convalescent beds do not have documented falls plans, including strategies to prevent falls and procedures for follow‑up after a fall occurs. Providing the Long Term Care Coordinator with education regarding all persons in care residing at F.W. Green Memorial Home require falls plans to be in place as per the legislative requirements. The absence of documented falls prevention and follow‑up plans presents a risk that falls are not effectively prevented, managed, or reviewed, which may increase the likelihood of injury and compromise the health and safety of persons in care. Submit by May 20, 2026, a written plan outlining how the contravention related to ensuring that all care plans include a falls 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 81(3)(e)(i)(ii)(iii)of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R10.4P - Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (Show More)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): R7.1Y - One bedroom is identified as not having a safe and secure location for the storage of valuable personal property. The infraction is discussed with the manager. The absence of a safe and secure location to store valuable personal property presents a risk of loss, damage, or unauthorized access, which may impact the security and well‑being of persons in care. Submit by May 20, 2026, a written plan outlining how the contravention related to ensuring that each bedroom includes a safe, secure place to store valuable property has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 29(1)(a) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 1 ) (a)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): R10.2A - A review of person in care records, discussions regarding admission requirements, and a physical inspection of the site there is no documented evidence of ongoing care planning or reassessment of safety measures to address their changing needs; thus ensuring their health and safety. Failure to implement additional measures when a person in care’s status or needs change presents a risk that care and supervision may not be appropriate or sufficient, potentially compromising the person in care’s health, safety, and well‑being. This is a re-occurring contravention from the December 2023 inspection. Submit by May 20, 2026, a written plan outlining how the contravention related to ensuring that the health and safety of each person in care is regularly monitored to determine if their needs continue to be met has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 50(1) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
    • 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): R10.3A - A review of care plans identifies that one care plan lacks specific guidance to staff regarding a person in care’s unique preferences related to night checks. While the person in care’s records include a documented managed risk agreement outlining this preference, the care plan does not provide direction to staff to ensure the preference is supported while maintaining the person in care’s health, safety, and dignity. Review of another person in care's file identifies that a care plan has not been developed. Without the development of care plans, or clear guidance in care plans, there is a risk that staff may not provide care in alignment with the person in care's preferences, which may impact their health, safety and dignity. This is a re-occurring contravention from the July 2023 and September 2025 inspection. As a result of the re-occurring contravention, submit by May 20, 2026, a written plan outlining how the contravention related to ensuring care plans take into account the unique preferences of persons in care has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 81(2)(b) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward. R10.3F - A review of care plans identifies that multiple persons in care occupying short‑stay and convalescent beds do not have a documented recreation and leisure plan. Discussion and education on the legislative requirements are provided to the Recreation Supervisor. The absence of documented recreation and leisure plans may result in unmet psychosocial needs, reduced engagement, and missed opportunities to support the overall well‑being and quality of life of persons in care. Submit by May 20, 2026, a written plan outlining how the contravention related to ensuring that all care plans include a recreation and leisure plan 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)(d) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward. R10.3M - Multiple gaps are identified within the current system to ensure care and supervision is provided in accordance with the terms and conditions of care plans. Documentation does not consistently demonstrate that care is delivered as outlined in care plans. - One care plan includes hourly overnight checks due to an increased risk of falls; however, night check documentation is not adjusted to reflect this requirement, and there is no documented evidence that the checks are completed as written. In addition, one person in care’s care plan outlines a specific type of night check, but documentation does not confirm that this care is provided. - A review of wound care plans and person in care's focus notes identifies no documented evidence that wound care is provided at the frequency outlined in the care plan for one person in care. Wound care planning and documentation are maintained using two methods—paper records and an electronic system (Pixalere). Documentation is not consistently aligned or maintained across both systems. Failure to ensure that care and supervision are provided in accordance with the terms and conditions of a person in care’s care plan presents a risk that care is inconsistent or inappropriate, which may negatively impact the person in care’s health, safety, and well‑being. This is a re-occurring contravention from the May 2024 inspection. Submit by May 20, 2026, a written plan outlining how the contravention related to ensuring that the care and supervision of persons in care is consistent with 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.
      • R10.3A - 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)
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
      • 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
  2. Routine Inspection Follow-up

    2 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The restraint monitoring record related to the incident report submitted to Licensing, does not include written evidence of 15 minute safety check monitoring of the person in care, entered at the time of the incident, in accordance with the requirements set out in the care plan of the person in care. Section 84(d) of the Residential Care Regulation requires that a record be kept indicating adequate monitoring of a person in care for the duration of a restraint. The purpose of this is to ensure the health, safety and dignity of the person in care. Licensing must receive written notification that adequate restraint monitoring procedures are in place to ensure compliance with Residential Care Regulation 84(d) no later than April 20, 2026.
      • 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)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Care plan documentation entered immediately or soon after the incident does not include evidence of communication or attempted communication with the person in care regarding the use of the restraint. Section 73(3)(b) of the Residential Care Regulation requires that advice and information be given to a person in care following the use of an emergency restraint. The purpose of this is to ensure the health, safety and dignity of the person in care. Licensing must receive written notification that adequate emergency restraint record keeping procedures are in place to ensure compliance with Residential Care Regulation 73(3)(b) no later than April 20, 2026.
      • R10.4K - Document in the care plan, the advice and information given following the use of an emergency restraint; 73( 3 )(b)
  3. Routine Inspection Follow-up

    0 infractions

  4. Routine Inspection

    7 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): R4.2D - A review of medication administration records (MAR), identified that the date, time, amount and effectiveness of a medication administered was not recorded as required for multiple as needed medications (PRN). Incomplete documentation of PRN medication administration may result in inconsistent or inappropriate medication practices, placing persons in care at risk for mediation errors. Submit by October 14, 2025, a written plan outlining how the contravention related to ensuring that a medication administration record includes the date, amount and time at which 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, thereby 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)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): R4.5G - A review of person in care's progress notes identified that multiple reportable incidents had not been reported to Licensing as required. Education was provided to the licensee on Schedule D definitions during the inspection. Failure to report incidents as required may result in delayed oversight and monitoring by Licensing, which could place persons in care at risk if concerns are not addressed in a timely manner. This is a re-occurring contravention from the November 2022, March 2023, March 2024, and August 2024 inspections. Submit by October 14, 2025, a written plan outlining how the contravention related to ensuring Licensing is immediately notified in the form and manner required of all reportable incidents has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 77(2)(c) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • 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)
    • 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): R2.1S - A review of person in care's records, including progress notes, completed Code White reports, and the Code White binder, identified that a Code White event involving a restraint was not implemented as per the policy. In addition, there was no documented evidence of follow up completed after multiple Code White events. Failure to follow the Code White policy and document follow up may compromise the safety and well being of persons in care and increase the likelihood of injury during emergency or high risk situations. Submit by October 14, 2025, a written plan outlining how the contravention related to ensuring policies are implemented by the licensee/manager as well as employees has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 85(1)(d) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • 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): R3.1N - A review of performance evaluation records indicated that the plan submitted in February 2025 for the Clinical Care team was not implemented as outlined by the manager. Since March 2025, the manager has completed five performance evaluations. There was documented evidence that the plan submitted in February 2025 by the Support Services supervisor was implemented. Failure to implement the performance evaluation plan as submitted may result in inconsistent monitoring of staff performance, gaps in accountability, and reduced oversight of quality of care and service delivery. This is an ongoing contravention from the March 2024 and February 2025 inspections. Submit by October 14, 2025, a written plan outlining how the contravention related to ensuring the performance of each employee is reviewed regularly has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 40(1)(a)(b) of the Residential Care Regulation, thereby ensuring sustained compliance 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): R7.1J - During the inspection of the physical facility, it was noted that a ceiling tile was missing the Turner Unit. A large soaker pad and a bucket were placed on the floor directly beneath the open ceiling in the main hallway leading to person in care's bedrooms, which was accessible to persons in care while also increasing the risk of slips, trips and falls. Failure to maintain the physical environment in good repair may create health and safety hazards, including the risk of slips, trips, and falls for persons in care. Submit by October 14, 2025, a written plan outlining how the contravention related to ensuring all rooms and common areas are maintained in a safe and clean condition has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 22(1)(c) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): R10.2V - A review of care plans identified that one person in care who was receiving ongoing room tray service did not have this information outlined in their care plan. The person in care's records did include the 30-day reassessment completed by the dietician. The care plan was updated and corrected during the inspection. If care plans are not updated to reflect current needs, there is a risk that persons in care may not consistently received care services as required. Submit by October 14, 2025, a written plan outlining how the contravention related to ensuring that ongoing room tray service is included in 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 63(3)(c)(ii) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • 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): R10.3A - A review of care plans identified that one care plan lacked specific guidance for staff regarding a person in care's unique preferences related to night checks. While the person in care's records included a documented managed risk agreement outlining this preference, the care plan did not provide direction to staff to ensure the preference was met while also maintaining the person in care's health, safety and dignity. Without clear guidance in care plans, there is a risk that staff may not provide care in alignment with the person in care's preferences, which may impact their health, safety and dignity. This is a re-occurring contravention from the July 2023 inspection. Submit by October 14, 2025, a written plan outlining how the contravention related to ensuring care plans take into account the unique preferences of persons in care has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 81(2)(b) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • 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)
  5. Routine Inspection

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): R3.1N requires the licensee ensures 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. During this inspection there was no documented evidence of performance reviews being completed for Support Services, as per the plan created following the May 2024 routine inspection. The Clinical Care team had documented evidence of three performance reviews being completed between May 2024, and February 2025. There was no evidence that the plan created following the May 2024 inspection was fully implemented, or monitored for effectiveness. At the time of this inspection it was noted that the licensee has implemented a new format for conducting performance reviews. This is an on-going contravention from the May 2024 inspection.
      • 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)
  6. Routine Inspection Follow-up

    5 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system to ensure the medication administration record (MAR) record shows the date, amount, and time at which medications were administered is ineffective. During a review of the person in care's medication administration record (MAR), multiple medications administered, as evidenced by focus notes which documented the administration of medication to the person in care, were were not recorded on the MAR. One as needed medication (PRN) was documented on the PRN Medication Record, however, the medication was not signed for on the MAR. As per documentation in the focus notes, the person in care began receiving care earlier than when medications were documented and signed for in the MAR. Residential Care Regulation, Section 78(2)(b), is a re-occurring contravention from the April 2022 and November 2022 inspections.
      • 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 system to ensure Licensing is notified immediately in the form and manner required is ineffective. The licensee did not submit the Reportable Incident Report to Licensing immediately following the incident as required. Licensing received the incident report 48 hours following the incident. This is a re-occurring contravention from the November 2022, March 2023, and May 2024 inspections.
      • 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): During the investigation of a reportable incident, it was identified that the licensee was providing a type of care that is not specified on the license. The licensee is currently licensed to provide Long Term Care, and is defined in the Residential Care Regulation as, "being residential care for persons with chronic or progressive conditions, primarily due to the aging process". The system to ensure care and services provided are regularly monitored is ineffective, as noted by the number of contraventions identified within this inspection report. During a review of the person in care's chart it was noted that documentation was inconsistent with the care and services provided, multiple documents were noted to be missing dates and signatures as required, and multiple forms were also noted to be incomplete, and contained differing and inconsistent information. Residential Care Regulation, Section 61, is a re-occurring contravention from the November 2022, March 2023 and April 2023 inspections.
      • R1.1T - Provide only the type of care that is specified on the license; 46( 2 )(a)
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The system to ensure policies are implemented by employees is ineffective. During the investigation, it was identified that the Code White Response Plan - Procedural Guidelines, were not being implemented. There was no documented evidence that the licensee has been recording Code White events as per the December 12, 2022 updates. During the investigation it was noted that multiple documents were incomplete, as well as missing dates and signatures. It was also noted that the person in care's chart contained duplicate documents that contained differing information. This is a re-occurring contravention from the November 2022 and March 2023 inspections.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system to ensure a record is kept of the date of admission for persons in care is ineffective. Upon review it was noted that the person in care's chart contained differing dates of admission. The documentation in their focus notes indicate an admission date earlier than the dates noted on other documents in their chart.
      • R4.1C - Keep a record of the date of admission for persons in care; 77.1( 1 )(a)
  7. Routine Inspection

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): R4.5D requires the Licensee to immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident. During the inspection, the Licensing Officer reviewed a random selection of client records, and records of submitted incident reports. Of the random selection of records, two reportable incidents were documented in person in care's progress notes, neither of which were submitted to Licensing as required in R4.5D. The Licensing Officer communicated this observed contravention to the Licensee during the inspection and provided teaching around the definitions of reportable incidents as outlined in Schedule D of the Residential Care Regulation. This contravention is re-occurring from the November 2022 and March 2023 inspections.
      • 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): R1.1W requires the licensee to regularly monitor the physical environment and the care services provided. During the inspection, the Licensing Officer reviewed the compliance plan submitted to Licensing following the December 2023 inspection. Two corrective actions identified within the compliance plan included the creation of checklists for monitoring. Of the two actions, there was no documented record of the checklists being created. The Licensing Officer was advised by employees that they were unaware that the checklists had not been completed. There was no documented evidence of review, or monitoring of the December 2023 compliance plan for implementation, or effectiveness of the plan. The Licensing Officer also reviewed audits of the care and services provided, person in care's records and engaged in discussions with employees. The results of the documented evidence resulting in non-compliance is captured within this report. This is a re-occurring contravention from the November 2022, February 2023 and April 2023 inspections.
      • 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): R3.1N requires the licensee ensures 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. There was no documented evidence of performance reviews being completed for Support Services, or the Clinical Care employees. Following the July 2023 inspection, the manager created a plan to ensure compliance with R3.1N to begin in January 2024. During this inspection, there was no documented evidence of this plan being implemented.
      • 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)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): R10.3C requires the licensee to ensure care plans include a plan to address behavioral intervention, if applicable. During the inspection, the Licensing Officer reviewed a behavioral care plan, corresponding progress notes and engaged in a discussion with employees regarding the documented plan. The current behavioral care plan did not have documented interventions to address the behaviors identified in the progress notes and confirmed by employees at the time of this inspection. R10.3M requires the licensee to ensure that the care and supervision of a person in care is consistent with the terms and conditions of a person's care plan. During the inspection, the Licensing Officer reviewed multiple person in care's charts. One care plan indicated safety checks to be completed, and there was no documented evidence that the checks had been completed as outlined in the care plan.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  8. Routine Inspection

    3 infractions

    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The system to ensure all medications on the person in care's medication administration record are recorded by the pharmacist is ineffective. A handwritten label was noted during a random audit of treatment administration records. The system to ensure plans for self-administration of medications is approved by the medication safety and advisory committee and medical or nurse practitioner is ineffective. Following a chart audit it was identified that a self-administration plan was included on a care plan, however, there was no evidence to confirm approval by the medication safety and advisory committee and physician.
      • R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
      • R9.1G - Permit self-administration of medication when a plan is approved by the medication safety and advisory committee and medical or nurse practitioner, and is included in the person's care plan; 70( 4 )(a)(b)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system to monitor the health and safety of each person in care regularly to determine if their needs continue to be met is ineffective. During a chart audit there was no evidence that scheduled 30 minute checks were completed. The system to ensure persons in care who may leave the facility without notifying an employee are fitted with identification that is not easily removed is ineffective. The system to ensure ongoing tray service is indicated in the care plan, and approved by the person in care's medical or nurse practitioner is ineffective. During a chart audit it was identified that a person in care who is receiving regular, ongoing tray service did not have approval from the person in care's medical practitioner, and was not receiving reassessments at least once every 30 days.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • R10.2M - Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56( 3 )(a)(b) (Show More)
      • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The system to ensure there is a plan for persons at risk of leaving the facility is ineffective. Persons in care identified as a risk of leaving the facility did not have a care plan to prevent or respond to a person leaving without notifying employees. This is a re-occurring contravention from the November 2022 inspection. The system to ensure care plans are reviewed in full, and modified if necessary is ineffective. During a random audit, multiple care plans were noted to contain outdated information.
      • R10.3G - Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  9. Routine Inspection

    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): The licensee does not currently have a system in place to ensure persons in care who leave the facility independently have a specific plan in place. During a care plan audit it was identified that a person in care identified as accessing the community independently did not have a specific plan detailing parameters for accessing the community, how to locate the person in care, directions for staff should the person in care not return, who to call, when to call etc.
      • 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): The system to ensure the name of the manager is displayed prominently is ineffective. It was noted during this inspection that the interim manager's name was 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): It was noted during the inspection that the system to ensure fridge temperatures are monitored for food safety is ineffective. This was noted by inconsistent documentation.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system to ensure all hazardous materials are stored securely is ineffective. During a random room audit it was identified that one person in care's room contained more than 10 disposable razors on the bathroom counter, accessible to persons in care. The system to ensure all medications are safely and securely stored is ineffective. During a random room audit medicated cream was noted to be accessible to persons in care as it was located on a low reaching, open shelf located in a person in care's bathroom.
      • 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): The licensee does not currently have a system in place to ensure persons in care who leave the facility independently have a specific plan in place. During a care plan audit it was identified that a person in care identified as accessing the community independently did not have a specific plan detailing parameters for accessing the community, how to locate the person in care, directions for staff should the person in care not return, who to call, when to call etc. The system to ensure medication care plans are reviewed, and modified if necessary is ineffective. During a random audit, multiple medication care plans were noted to be missing dates indicating when the plan was initiated, reviewed, and revised.
      • 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)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  10. Routine Inspection

    6 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The system to ensure restraint monitoring is completed is ineffective. During a review of resident charts it was noted that restraint monitoring documentation was missing for an active restraint, inconsistently completed, and some records were noted to be documented prior to being monitored. This contravention is ongoing from the April 2022 and November 2022 routine inspections.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing acknowledges effort to increase self-monitoring of the care and services provided via the development of an audit binder. However, monitoring to ensure compliance was ineffective as noted by the number of ongoing, re-occurring and new contraventions in this report. This is an ongoing contravention from the November 2022 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): The system to ensure policies are implemented by employees is ineffective. Through random chart audits, observations of staff, and review of various documentation on site, it was noted that policies related to the following areas were not being implemented: 1)Restraints 2) Restraint Monitoring 3) Processing orders 4) Hand written labels 5) Documentation. On a routine follow up inspection conducted in March 2023, Licensing identified non-compliance with the Code Yellow policy. During this routine inspection there was no documented evidence that the licensee had implemented the action plan.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system to ensure as needed medication (PRN) effectiveness is documented is ineffective. During a random audit of medication administration records it was noted that PRN effectiveness was inconsistently documented on multiple charts. This is a re-occurring contravention from the April 2022 routine inspection.
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R4.6 - Are facility records current and complete?
      • Observation(s): The Licensee does not have a system in place to ensure that Medication Safety Advisory Committee meeting minutes are retained on site, and/or that the Pharmacist's recommendations are reviewed and followed up on by employees.
      • R4.6A - Keep a copy of each policy and procedure of the medication safety and advisory committee; 85 ( 3 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The system to ensure all medications on the person in care's medication administration record are recorded by the pharmacist is ineffective. A handwritten label was noted during a random audit of medication administration records. This is an ongoing contravention from the November 2022 routine inspection.
      • R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
  11. Routine Inspection Follow-up

    2 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): During conversation with the manager, it was identified that a reportable incident, was not immediately reported to Licensing. This Licensing Officer has previously provided education to the Licensee on Incident Reporting and Schedule D of the Residential Care Regulation. This is an on-going contravention from the November 17, 2022 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)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): During follow up of a reportable incident it was noted that a policy was not implemented by employees. This is an on-going contravention from the November 17, 2022 inspection.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  12. Routine Inspection Follow-up

    0 infractions

  13. Routine Inspection

    12 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Treatment Administration Records (TARs) were noted to be incomplete. There was no evidence of treatment being provided as per Doctors orders. This contravention was also noted on the previous inspection completed in April 2022.
      • 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): The system in place to ensure that persons in care are monitored while using a restraint was ineffective. This contravention was also noted on the previous inspection completed in April 2022.
      • 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)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): In review of person in care's records it was noted that incidents were not reported to Licensing as required. This Licensing Officer has previously provided education to the Licensee on Incident Reporting and Schedule D of the Residential Care Regulation. In addition, this education was provided to the RN during this 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)
    • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): The system to ensure persons in care are encouraged to participate in programmed activities is ineffective. A review of the Recreation Attendance Records in a persons care plan were noted to only be marked with an 'A' (Active) sporadically. There is no evidence to suggest the person in care was encouraged, or refused participation.
      • R8.1B - Encourage persons in care to participate in the program of activities provided (Does not apply to Hospice); 55( 1 )(b)(i)
    • RB1.15 - Are persons in care encouraged to participate in the facility's program of activities and to take advantage of opportunities available in the community?
      • Observation(s): The system to ensure persons in care are encouraged to participate in programmed activities is ineffective. A review of the Recreation Attendance Records in a persons care plan were noted to only be marked with an 'A' (Active) sporadically. There is no evidence to suggest the person in care was encouraged, or refused participation.
    • RB1.22 - Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): It was noted during the inspection that one nursing station did not have a system to ensure confidentiality of person in care's records and personal information.
      • RB1.22A - Respect personal privacy and keep records and personal information confidential.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The system for self-monitoring was ineffective as noted by the number of contraventions identified in this report, as well as the number of on-going contraventions identified.
      • 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): The system to ensure that each person in care's weights are recorded monthly is ineffective. In reviewing a person in care's record it was noted that monthly weights were not recorded consistently, and there was no evidence to suggest the person in care had refused to be weighed. This contravention was also noted on the previous inspection completed in April 2022. It was noted during the inspection that one nursing station did not have a system to ensure confidentiality of person in care's records and personal information.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
      • R4.1S - Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): A bottle of chemical cleaner was noted to be accessible to persons in care in an unlocked cupboard under a sink in a common area. This contravention was also noted on the previous inspection completed in April 2022. It was noted that there is no shelter from inclement weather, including the persons in care designated smoking area.
      • 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)
      • R7.1AN - Provide outside activity areas that have comfortable seating including a reasonable amount of shelter from sun and inclement weather; 36 ( 1 ) (c)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Handwritten labels were noted in medication administration records.
      • R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Oral Care Plans do not contain resident specific plans for oral hygiene, no documented evidence to indicate persons in care were encouraged to be examined by a dental health care professional in the past year, or any evidence of a pending appointment. Persons in care who are assessed as being able to leave the building independently, including those who leave the premise to smoke, currently do not have documentation on them that indicates their name, facility name and emergency contact information. The system to approve, and reassess ongoing tray service is ineffective. In review of person in care's records there was no documented evidence of reassessment for ongoing tray service as required.
      • R10.2H - Encourage persons in care to be examined by a dental health care professional at least once every year; 54( 3 )(a)
      • 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 )
      • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The system to ensure there is a plan for persons at risk of leaving the facility is ineffective. Persons in care identified as a risk of leaving the facility did not have a care plan to prevent or respond to a person leaving without notifying employees.
      • R10.3G - Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
  14. Routine Inspection

    6 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Treatment Administration Records (TARs) were noted to be incomplete. Regularly scheduled treatments were not signed as given.
      • 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): The system to ensure that restraint monitoring documentation is completed was ineffective. It was noted that the restraint monitoring documentation was inconsistent, as noted with multiple days with no 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): It was observed that the effectiveness of as needed medications (PRNs) was not consistently documented. The system to monitor the employees documenting PRN effectiveness, was ineffective. (This is a historical contravention)
      • R3.1X - 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): It was observed that monthly weight records, located in the tub room were incomplete. During a random audit of charts it was also noted that multiple persons in cares charts had monthly weights documented inconsistently . The system to ensure each person in care is weighed, and their weight is recorded monthly was ineffective.
      • R4.1R - 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): A bottle of chemical cleaner was noted to be accessible to persons in care in an unlocked cupboard on the Turner unit.
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The system to ensure each person in care has a care plan to address medication was ineffective. During a random audit of the medication administration record it was noted that multiple person in care were missing a plan to address medication. It was also noted that some plans did not include a date to indicate a review, or directions that the plan was still current.
      • R10.3B - Care plans must include a plan to address medication, including self-medication; 81( 3 )(a)(i)
  15. Routine Inspection

    3 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): The facility did not have a system in place to advise the person in care, or the person's representative of how to express a concern or make a complaint to licensing. It was observed that the effectiveness of PRN was not consistently documented as per facility policy. The system to monitor the employees documenting PRN effectiveness, was ineffective as the effectiveness was noted to be missing in some of the Medication Administration Records documentation. (This is a historical contravention)
      • 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)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): It was observed that although items on the posted menu were substituted, there was not a system in place to track the substituted items. Please provide licensing with the system the facility will utilize to track substitutions.
      • R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It was noted that a person in care was assessed as an elopement risk. The facility did not have a system in place to ensure the elopement risks had identification on their persons that could not be easily removed. Facility's system is the use of 'wander-guard', which does not meet the intent of RCR 56(3)(a(b). Please provide to licensing the system the facility will put in place to ensure that persons in care who are an elopement risk, and that may not be capable of identifying themselves have some form of identification.
      • 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)
  16. Monitoring

    4 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Restraint charting did not consistently indicate monitoring as per facility policy. Review dates also missing. Inform licensing of what audits will be put in place to ensure charting is consistent with restraint plan.
      • R2.2B - Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73( 2 ); 75( 2 )(a)(i)(ii)(b)
    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Treatment Administration Records (TARS) are not consistently recorded. Inform licensing on the audit system that will be in place to review that TARS are completed in full.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Regular performance reviews are not up to date for all employees. Inform licensing on what plans will be in place to ensure that performance reviews are completed. Provide information on what systems will be put in place to ensure that each employee is regularly reviewed.
      • 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)
    • 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 wound care plans reviewed were not consistently documented in accordance with the identified plan. Inform licensing on what audit system will be put in place to ensure documentation is completed.
      • 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
  17. Monitoring

    3 infractions

    • 9.2 Does the supervising pharmacist consult with employees respecting medication interactions and other problems related to medication?
      • Observation(s): Licensing observed that regular Medication Safety and Advisory Committee (MSAC) meetings are not occurring regularly. (Manager reported that the Pharmacist will be out in November to have a meeting)
      • Appoint a supervising pharmacist to consult with employees respecting medication interactions and other problems related to medication; 68( 2 )(c)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing observed prescription creams/ointments in resident rooms that are accessible to PIC. Corrected During Inspection (CDI) Facility noted to have areas that have chipped paint and holes in the wall which does not maintain rooms and common areas in a good state of repair (ie main floor bathroom near ADP area, Sandberg and Gummer until common walls, resident rooms, and door ways.) Licensing observed cream bathroom cleanser in a unlocked cupboard in the upstairs kitchen. This was noted during the previous inspection. (CDI) Observed caviwipes accessible to PIC in Physio area (CDI) One PIC noted to have numerous disposable razors accessible to other PIC -Noted on previous inspection (CDI)
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 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)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): Licensing observed prescription creams/ointments in resident rooms that are accessible to PIC.
  18. Monitoring

    3 infractions

    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The upstairs MAR shows that the effectiveness of PRN medications is not consistently being documented. This is an outstanding contravention.
      • Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The hot water upstairs was measured to be 56 to 58 degrees. This is an outstanding contravention. The outdoor smoking area is littered with cigarette butts. Numerous prescription creams/ointments were noted to be accessible in residents' bathrooms. This is an outstanding contravention. One resident had numerous disposable razors accessible in their bathroom. The dressing cart containing hydrogen peroxide, adhesive remover and Rub A535 was found to be unlocked. THIS WAS CORRECTED DURING THE INSPECTION. There was cream bathroom cleanser in an unlocked cupboard in the upstairs resident kitchen. THIS WAS CORRECTED DURING THE INSPECTION.
      • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 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): Although there are medication care plans in place, they are not dated and therefore LO is unable to ascertain whether or not they have been reviewed. Although there are falls care plans in place, the interventions highlighted next to the care plans are not dated, and therefore LO is unable to ascertain whether or not they have been reviewed.
      • Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  19. Monitoring

    10 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): 1) Staff were unable to locate the policies and procedures in required for assessing risks that may result in a person in care falling including a plan for prevention falls.
      • Written falls prevention policies and procedures are required for assessing risks that may result in a person in care falling including a plan for preventing falls, responding to falls suffered and including care and subsequent prevention(Applies only to Long Term Care); 85(2)(a)(i)(ii)(iii).
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): In one resident's chart the tuberculosis records was not available for licensing's review.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 (3)
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): 1) The environment is not maintained to prevent falls as previously noted in 7.1 - 2 Outdoor designated activity area has uneven transition from cement/bricks walk way which poses a risk for falling for persons in care. In addition there are two old cement pilings that pose a risk of tripping for residents.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The facility is not regularly monitor the physical environment (see section 7 Physical infractions).
      • Regularly monitor the physical environment and the care and services provided; 61
    • 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): 1) Staff were unable to locate policies and procedures related to residential care. 2) The facility does not have a policy and procedure in place respecting access to person in care by people who are not employees and the release of vulnerable adults from a facility. Please be advised this was an outstanding infraction from the inspection done July 16, 2014.
      • 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)
      • Ensure there are written policies and procedures regarding the release of children, youths and vulnerable adults by authorized persons, including if an authorized person appears to be incapable of providing safe care to the person in care; 85(2)(f)(i)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): 1) In one resident's chart the height was recorded but not the weight.
      • Record the height and weight of each person in care on admission; 49 (4)
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): 1) Some food stored in the upstairs resident fridge had no expiry date.
      • Provide a variety of foods in consideration of texture, colour, food safety, taste, and visual appeal; 62(2)(c)(iv)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): 1) Hot water exceeds 49 degrees Celsius. Please correct by 12-May-2015. 2) Commercial coffee maker with hot water enabled is accessible to persons in care. 3) Outdoor designated activity area has uneven transition from cement to bricks on the walk way which poses a risk for falling for persons in care. In addition there are two old cement pilings that pose a risk of tripping for residents. Please flag these areas as a risk until area corrected. 4) Heating register not covered and has sharp edges present. This is accessible to persons in care. Please correct by 12-May-2015. 5) Roofing shingles noted on ground in outdoor recreation area. 6) Excessive amount of lint noted coming from a dryer vent into the outdoor recreation. In addition the recreation area tables and chairs were not clean and ready for use by residents. 7) Paint is peeling on the outdoor recreation benches. 8) Some ceiling tiles appeared to have water stains present. 9) Door with signage indicating that it should be locked was found unlocked. 10) Emergency exit obstructed on main floor. Please correct by 12-May-2015 11) Cigarette butts noted in outdoor recreation area. Please correct by 12-May-2015
      • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
      • Maintain all rooms and common areas in a safe and clean condition; 22(1)(c)
      • Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 (4)
      • Ensure that employees do not smoke while supervising persons in care; 23(b)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): 1) Prescription creams found unlocked cupboards in several resident's rooms. In addition hydrogen peroxide was found in an unlocked wound care nursing cart which was accessible to persons in care. Ensure medications are stored in a safe and secure area as per Residential Care Regulation 69 (3) (a). 2) PRN medication effectiveness or ineffectiveness is not always charted. Ensure response to medications administered is documented as per Residential Care Regulation 68.
    • 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 care plans reviewed this date were not up-to-date.
      • Each care plan must be monitored on a regular basis to ensure proper implementation; 81(4)(a)