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Garden Avenue

110 12th Ave S Cranbrook BC V1C 2S1 · Residential Care - Licensing

3 inspections

  1. Routine Inspection

    2 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): R4.5G - A review of internal incident reports identified that a reportable incident was not reported to Licensing as required. The incident was reviewed during the inspection, and education was provided on Schedule D definitions of reportable incidents. Failure to report a reportable incident to Licensing as required under the Residential Care Regulation may delay regulatory oversight, increasing the risk of harm to persons in care and limiting the licensee's ability to demonstrate compliance. Submit by November 28, 2025, a written plan outlining how the contravention related to ensuring that all reportable incidents are reported to Licensing, 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)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): R10.4G - A review of care plans indicated that the use, type, and duration of the restraint were not documented in the care plan. Without documentation of the use, type, and duration of a restraint in the care plan, there is a risk that staff may apply restraints inconsistently or inappropriately, potentially compromising the safety and rights of the person in care. Submit by November 28, 2025, a written plan outlining how the contravention related to ensuring the use, type and duration of a restraint is documented 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 73(2)(c) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • 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
  2. Routine Inspection

    1 infraction

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): R7.1AK - The system to ensure cleaning agents are safely and securely stored is ineffective. It was noted during the inspection that laundry cleaning products were accessible to persons in care located on an open shelf in an unlocked laundry room. R7.1AO - The system to ensure the outside activity area is secured in order to protect the health and safety of persons in care is ineffective. It was identified during the inspection that persons in care were utilizing an outdoor area located in the front of the home, that contained uneven ground, an unfenced ledge with approximately a 4ft. drop to a concrete sidewalk, as well as multiple metal rods protruding from the concrete ledge posing a safety hazard.
      • 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)
      • R7.1AO - Ensure the outside activity area is secured by a fence or other means, if necessary to protect the health and safety of persons in care; 36 ( 2 )
  3. Routine Inspection

    4 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): It was identified during the inspection that a restraint did not have written agreements in place by both the person in care or their representatives, medical practitioner or nurse practitioner.
      • R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): It was identified during this inspection that there is currently no record of the duration of a restraint and the monitoring of the person in care during the restraint.
      • 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): During this inspection it was identified that the system to ensure all employees comply with the policies and procedures of the medication safety and advisory committee is ineffective. During a random audit of medication administration records inconsistencies were noted in signatures, as well as documentation related to as needed medication times and amounts.
      • 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): During a random audit of documentation it was identified that the system to ensure records are kept in a single place is ineffective. When asking the licensee to produce records for review, requested records/documents were not easily retrieved.
      • R4.6N - Keep the following records in a single place at the facility: Records for each person in care [section 78], records respecting money and valuables of persons in care [section 79], short term care plan on admission [section 80], care plan for more than 30 day stay [section 81], policies and procedures [section 85], repayment agreements (section 85.1) record of minor and reportable incidents [section 88] and record of complaints and compliance [section 89]; 91( 2 )(a) (Show More)