Gemstone Care Centre
1955 Tranquille Rd Kamloops BC V2B 3M4 · Residential Care - Licensing
10 inspections
- Routine Inspection
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): Two person in care's care plans were reviewed that have been assessed as capable to go out to community independently. The care plans did not include plans of how to locate the persons in care should they not return within the agreed upon time frame. One of the care plans did not include a plan of how the person would notify staff of their departure. When a care plan does not include all elements regarding independent outings for those persons in care that are capable, this increases the risk of a delay in response in cases of emergency. Submit a detailed plan of how the Licensee will ensure that all care plans for persons in care capable of independent outings include a plan to locate them and for how the person in care should notify staff of their departure, no later than November 17, 2025.
- 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)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Routine Inspection
0 infractions
- Routine Inspection
5 infractions
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): In one spa room, there was an unlabeled brush in the common vanity drawer. All other persons in care items were kept separated, in labeled baskets, for personal use.
- R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Manager reported that not all staff performance reviews have been completed, on an annual basis, as per facility policy.
- 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): For two persons in care, there was no documentation of weights having been recorded, for two months each, within the last year.
- 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)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): A review of the posted menu, there was no evidence that two snacks per day, with at least two food groups at each snack, were being provided for each person in care per day. On the menu, there was a list of snacks along the bottom with a statement that they were provided "by request".
- R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): A bottle of cleaning/sanitizing solution, in one lounge, was accessible to persons in care while there were no staff present. This item was removed from the reach, of persons in care, during inspection. In one person in care's room, the medication cupboard, which contained a medicated cream, was unlocked and accessible to persons in care. Staff locked cupboard during inspection.
- 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)
- R7.2 - Is the environment maintained to prevent falls?
- Routine Inspection
3 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): In review for this routine inspection, incident reports since the last routine inspection were reviewed, at times reports to licensing were received 2 to 3 days (usually over a weekend) after the incident. Please review incident reporting procedures to ensure incident reports are submitted to Licensing Direct immediately.
- 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)
- R4.6 - Are facility records current and complete?
- Observation(s): ADL sheets in PIC rooms are to be reviewed monthly as per facility policy, in one section of the building ADL sheets for the month of May 2022 had been signed for, even though the inspection occurred on April 29, 2022.
- R4.6L - Ensure all records are current; 91( 1 )(a)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Ensure any persons in care with ongoing room tray service in place, have the plan reassessed at least once every 30 days by the person in care's medical or nurse practitioner or a dietician.
- 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
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): Some restraint and repositioning checks that were reviewed during this inspection were charted hours after the scheduled check, as charting is time stamped. Develop a process for staff to chart shortly after completion of checks to ensure accuracy, as well as a monitoring system to review checks on a consistent basis to ensure compliance with the process.
- 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
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Routine Inspection
0 infractions
- Routine Inspection
2 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Some treatment administration records reviewed during this inspection were noted to be charted inconsistently, some missing charting noted.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(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): LO identified inconsistencies in the system which identifies persons in care nutritional status changes and communicates the change to the kitchen. LO reviewed the records for restraint monitoring and treatment administration, a system to audit the charting of these two items was not in place at the time of inspection.
- R10.3E - Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (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
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
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): Facility policy indicates Activities of Daily Living documents in PIC rooms are to be reviewed monthly, Several ADL documents viewed during this inspection had not been updated for a few months. Inform Licensing on how the facility audits PIC ADL documentation to ensure it is updated monthly.
- 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): Ensure every PIC who leaves the building to smoke independently has a smoking plan in place for staff to access. Inform Licensing that the plans are in place and include your system for auditing plans. Some PIC's are able to leave the premises independently, ensure each PIC who can leave the premises independently has a plan in place to guide staff regarding: timeframes for return, what steps to take if PIC does not return within specified return time, Identification when offsite etc...Include in your response how these plans will be developed and audited.
- 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?
- Monitoring
3 infractions
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Some TAR's reviewed during this inspection were not charted consistently. This infraction was noted during the last Licensing inspection. The facility has a monitoring system in place for TAR charting since the last inspection but the charting was still found inconsistent during this visit. Inform Licensing on what changes will be made to the current monitoring system to ensure TAR charting is completed.
- Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
- Observation(s): TB test information not available in one of the staff files that was reviewed during this inspection. Facility does have a process in place to ensure required staff information is in place prior to commencing employment. Inform Licensing on if any changes are made to the current procedure and that the missing information is completed.
- Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Several medication storage cupboards in PIC bedrooms were found unlocked with medicated creams present. This was noted during the last Licensing inspection. Facility has a self monitoring procedure in place, inform licensing on what changes will be made to the procedure to ensure all medications remain inaccessible to PIC's.
- Ensure all medications are safely and securely stored; 69( 3 )(a)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
4 infractions
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Some TAR's reviewed during this inspection were not charted consistently. This infraction has been noted on consecutive Licensing inspections, Please submit a plan to Licensing on how the ongoing issue with TAR documentation will be followed up on by the facility.
- 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): Emergency evacuation procedures have been reviewed, however the plan to evacuate to a secondary location out of the neighbourhood if required needs review to ensure all information (contacts etc...) is still accurate.
- 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): Medication cupboards in PIC rooms which store medicated creams were found unlocked with medication present in two rooms. Ensure all medications are kept inaccessible to PIC's.
- Ensure all medications are safely and securely stored; 69( 3 )(a)
- 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 behavioural plans reviewed during this inspection did not include specific information for staff to help with the exhibited behaviour, some plans gave general information or referred to PIECES documentation which was not always available. Ensure each behavioural plan is specific to the PIC involved and any documents (PIECES etc...) are attached to care plan documentation.
- Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?