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Gillis House

1699 Tutill Crt Merritt BC V1K 1C6 · Residential Care - Licensing

15 inspections

  1. Routine Inspection

    5 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): This is an ongoing contravention. PRN (as needed) medications were observed during this inspection to have inconsistent charting for the effectiveness of the medication. Ensure the effectiveness of PRNs is observed and charted to allow for effective medication management. Submit a corrective action plan by September 19, 2025, which indicates what systems will be put in place to ensure PRN effectiveness is charted.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • 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 September 19, 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)
    • 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 September 19, 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The outdoor activity area contained several hazards at the time of this inspection: BBQ propane tanks accessible, raised tree roots which could cause a tripping hazard, low tree branches over a walking path and raised flower beds which were noted to be in poor condition. The outdoor area must be kept in clean and safe condition to help avoid potential injury to a person in care. Submit a corrective action plan by September 19, 2025, which indicates what systems will be put in place to ensure the outdoor area is kept safe and clean for use by persons in care. Within the building there were several areas/items observed which could be potentially hazardous to persons in care: A screw driver on a desk in an accessible area, a tub room door left open with cleaners accessible and two trap doors in the floor unlocked. Hazardous items and areas must be kept inaccessible to persons in care to help prevent injury/illness. Submit a corrective action plan by September 19, 2025, which details what systems will be put in place to ensure hazardous areas/items are kept inaccessible to person in care.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • 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): Several care plans for 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 September 19, 2025, 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)
  2. Routine Inspection

    5 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): PRN medication records reviewed during this inspection often did not include charting of the result of the medication.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Incident reports for the last year reviewed prior to this inspection; at times the section of the building is not noted (Hospital Act or Licensed LTC), some incident reports also lacked details of the incident as well as corrective actions if applicable.
      • 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Repeated Contravention - Performance evaluations for regular employees are behind schedule, please submit a plan indicating how the facility will complete overdue reviews and keep up to date 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): One of the outdoor courtyard areas observed with dusty tables and chairs, ensure outdoor areas are kept in a clean condition for use by persons in care. Some courtyard areas and the front entrance observed with large overgrown weeds, ensure areas accessible to persons in care are kept in a good state or repair.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 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 binders reviewed, a wound care plan remains in the binder with no recent charting, and no indication the wound has healed. Please review wound care procedures/charting and expectations.
      • 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
  3. Routine Inspection

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): A printed copy of the most recent routine inspection report (Dec 2022) was not posted in an area which is accessible to staff/visitors/persons in care.
      • 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): (Repeated Contravention) - Performance reviews of employees are not being completed on a regular basis, within the facility policy timeframes.
      • 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): Some Resident Data Contact sheets reviewed during this inspection did not include height/weight/hair colour/eye colour.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
    • 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): Please ensure any person in care who is able to leave the facility to smoke, has a detailed smoking care plan in place (processes for person in care to leave the building, information on storage of lighter/cigarette, ID for person in care, where does person in care smoke? how long until staff need to check on them? Is a smoking apron needed? etc.). Please ensure smoking assessments are completed on a regular basis. Some smoking care plans observed during this inspection, more specific details required.
      • 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)
  4. Routine Inspection

    5 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): A review of person in care's restraint monitoring showed no evidence of completion of checks as care planned in several person in care's charts.
      • R4.3F - Keep a record of employee compliance with the requirements of Division 5 (Use of Restraints) of Part 5 in the persons care plan; 84 (f)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): A review of person in care's charts showed no evidence of immunization records in any charts reviewed. The staff informed they did not have the practice to collect this information due to it being unavailable at admission and did not have a practice in place to document the information was unavailable.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): (Repeated contravention from previous inspection)- Performance reviews of employees were not completed on a regular basis, within the facility's policy timeframe.
      • 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): An emergency exit at the end of one hallway where resident rooms were present showed no evidence of having been cleared of snow for safe exit in case of emergency. All other emergency exits showed evidence of regular snow removal. One utility room door with a lock present was accessible to persons in care, where cleaning agents were present.
      • R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
      • 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): Several wound treatment plan were reviewed, and found that the treatment sheets were not consistently completed as required. The treatment sheets reviewed were missing pertinent information to guide employees in providing wound care, and at times there was no documentation to indicate that treatment was completed.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  5. Routine Inspection

    3 infractions

    • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Currently recreation is offered 7 days a week in one portion of the building and 5 days a week in another, please review recreation programming offered throughout the building to ensure it is suitable to meet the needs of all Persons in Care.
      • R8.1A - Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55( 1 )(a)(i)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): This contravention remains unresolved from the June 16, 2021 routine inspection. Staff performance evaluations are overdue. Gillis has had several changes in leadership over the last year, a new manager is in place since September 2021, please submit a plan on how overdue staff performance evaluations will be completed and kept up to date 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)
    • 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): Please review current smoking care plans to ensure they include specific instructions for staff to support the PIC's, as well as assessments to ensure PIC's are able to safely follow the developed care plan.
      • 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)
  6. Routine Inspection

    6 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): This contravention remains unresolved from the March 18, 2021 inspection. Administered PRN medications showed inconsistent documentation as to the reason they were administered and their effectiveness.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): This contravention remains unresolved from the March 18, 2021 routine inspection. Facility has developed auditing systems for Section 61 since the last inspection, and are beginning to implement those audits. Work towards resolving this contravention was evident during this inspection. Some items noted during this inspection in regard to facility self monitoring: Wound care charting not aligning with wound care plans and some progress notes inconsistently containing a response or follow-up to previously noted concerns.
      • 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): This contravention (RCR 40(1)(a)(b) remains unresolved from the March 18, 2021 inspection. Facility leadership has changed since the last licensing inspection. Gillis has submitted a compliance plan since the last inspection which includes a plan to complete overdue staff performance evaluations. Please submit a status update regarding the progress completed. New contravention: Facility emergency drills have not been practiced recently, during this inspection it was discussed that plans were in progress to re-implement facility emergency training drills. Please submit a plan on how all employees will receive ongoing training in regard to facility emergency plans.
      • 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)
      • R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): This contravention remains unresolved from the March 18, 2021 inspection. In several charts reviewed, the wound treatment sheets were inconsistent in charting with the wound care plans. In one instance the wound care was complete, however the plan remained in the wound care binder.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): This contravention remains unresolved from the March 18, 2021 inspection. Several PIC progress notes reviewed during this inspection did not contain a response or indicate any follow-up to previously noted concerns. The specific examples were relayed to facility leadership at the time of inspection.
      • 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): This contravention remains unresolved from the March 18, 2021 inspection. Wound care charting reviewed during this inspection was inconsistent in several circumstances with the wound care plan. Although evidence of care plan reviews was evident during this inspection, wound care charting requires additional auditing to ensure proper implementation of wound care plans.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  7. Routine Inspection

    13 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): There is no system in place for the monitoring of Medication and Treatment Administration Records to ensure they are completed as required. Upon the review of the Medication and Treatment Administration Records employee initials were noted to be missing for routinely administered medications. Administered "PRN" medications and treatments showed inconsistent documentation as to the reason they were administered and their effectiveness.
      • 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): Please see comment above in section R4.2
    • R9.2 - Does the supervising pharmacist consult with employees respecting medication interactions and other problems related to medication?
      • Observation(s): See comments above in section R9.1
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): This contravention is reoccurring from the April 11, 2019 Routine Inspection. There is no system in place to monitor employees to ensure they are documenting restraint safety checks throughout their shifts as required by the facility's restraint policy and procedure.
      • R10.4C - Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): This contravention is reoccurring from the April 11, 2019 Routine Inspection. There is no system in place to regularly monitor the care and services provided to persons in care. This is evident by the contraventions noted in this inspection report.
      • 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): This contravention remains UNRESOLVED from the August 28, 2019 Routine Inspection. The system that is in place for ensuring employees implement the facility's policies and procedures is ineffective. 1) There is a noticeable improvement regarding documentation in persons in care's progress notes; however, documentation remains inconsistent. This Licensing Officer reviewed persons in care's progress notes and observed persons in care who had changes in their conditions; however the documentation did not consistently contain the Data, Action, Response or Plan information as required by the facility's policy and procedure. This contravention is reoccurring from the April 11, 2019 Routine Inspection. 2) There is no system in place for the formal orientation of new Managers and Long Term Care Coordinators to the facility, including orientation to the Residential Care Regulation and the Community Care and Assisted Living Act. 3) There is no system in place to ensure employees follow the facility's policy and procedure for responsive behaviours. This Licensing Officer reviewed progress notes of persons in care with responsive behaviours and noted that reassessments are not consistently conducted or documented as per the facility's "AGG" policy and procedure.
      • 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 contraventions remains UNRESOLVED from the April 11, 2019 Routine Inspection. The system in place to ensure that the performance of each employee is reviewed regularly is ineffective. In discussions with the facility Manager it was identified they are designated to the Long Term Care Facility one to two days a week. Therefore, the employees have not been regularly monitored nor are performance appraisals completed as required. The performance appraisals for the LPNs are documented; however, they have not been reviewed with the employees.
      • 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): This contraventions is reoccurring from the April 11, 2019 Routine Inspection. The system in place for the monthly weighing and recording of persons in care's weights is ineffective. Upon review of person's in care's charts it was identified that the weighing and documentation of person's monthly weights is inconsistent.
      • 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): During the physical inspection of the facility, it was noted that the incorrect week of the four week menu was posted. It was also noted that the menu written on the daily board did not reflect the four week menu and it was different in each dining room throughout the facility. In the review of the posted four week menu, it was noted that the breakfast meal does not meet Canada's Food Guide each day of the week, as a protein is missing from three meals in a week.
      • R5.1C - Provide for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups described in Canada's Food Guide; 62( 2 )(a)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): This contraventions remains UNRESOLVED from the August 28, 2019 Routine Inspection. The system that has been put into place to ensure persons in care's health and hygiene is maintained is ineffective. 1) This Licensing Officer reviewed a person in care's wound treatment plan, and found that the treatment sheets were not consistently completed as required. The treatment sheets reviewed were missing pertinent information to guide employees in providing wound care, and there was no documentation to indicate that treatment was completed. This is a reoccurring contravention that has been noted on inspections in previous years. 2) Upon the physical inspection of a tub room, unlabelled personal hygiene products (nail clippers, comb, nail scissors) were observed.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): There is no process in place for the establishment of a Medication Safety and Advisory Committee (MSAC). There is currently no MSAC in place.
      • 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): This is an UNRESOLVED contravention from the April 19, 2019 Routine Inspection. 1) There is no system in place to ensure the health and safety of each person in care is monitored regularly to ensure their needs continue to be met. Upon review of persons in care's progress notes, this Licensing Officer noted documentation indicating a person in care experienced a change in their condition over two days. Following the two days the documentation ended without indicating if the doctor or family were notified, or if the person in care's condition improved or deteriorated further. During the review of persons in care's charts, this Licensing Officer noted nursing actions did not take place for 17 days following a Doctor's written order. Documentation was not located to indicate why the delay occurred. In discussions with the Care Coordinator, the process for contacting doctors in regards to concerns with persons in care often occurs over text messages from the RN cell phone to the doctors. However, these communications are not documented in the persons in care's progress notes or doctors orders, resulting in difficulty in tracking doctor's orders and their completion. 2) Prior to the Pandemic, the Resident and Family Council met monthly and the meeting minutes were posted in the facility; however, since the start of the pandemic a meeting has not occurred. This Licensing Officer, the Facility Manager and the Long Term Care Coordinator discussed ideas as to how an opportunity could be provided to Families and Residents to come together in the form of a virtual council. Please include a plan for future Family and Resident council meetings in the compliance plan to be submitted to Licensing by April 09, 2021.
      • 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): There is no system in place to ensure that persons in care and their representatives are involved in care planning when a change is made to their care plan. There is no system in place to ensure that employees are following persons in care's care plans. This Licensing Officer noted documentation in a person in care's progress notes stating a person in care complained of pain and a "PRN" Tylenol was given. A nursing assessment including location and severity of pain was not documented in the progress notes or on the Medication Administration Record, nor was a pain scale completed as per the person's care plan. Persons in care's "My Days" posted in their room to guide their care and supervision were noted to not reflect their dietary care plan. Upon the review of two persons in care's "My days" and care plans, it was noted the dietary care plan indicated therapeutic diets that were not reflected on their "My day".
      • 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)
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  8. 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 system that is in place for ensuring employees implement the facility's policies is ineffective. Licensing Officer (LO) reviewed persons in care's progress notes and found that employees are not following the facility's documentation policy. It was noted that persons in care had changes in their conditions; however the documentation did not contain the Data, Action, Response information as required by the policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system that has been put into place to ensure persons in care's health and hygiene is maintained is ineffective. LO reviewed a person in care's wound treatment plan, and found that the treatment sheets were not consistently completed as required. The treatments sheets reviewed were missing pertinent information to guide employees in providing the wound care ordered, and there was no documentation to indicate that the treatment was provided as ordered. The monitoring of the system that was put into place for wound care is ineffective as this non-compliance was not identified by the individual responsible for the auditing of the system.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): 1) The system that has been put into place to monitor persons in care to ensure their needs continue to be met is ineffective. LO reviewed progress notes in person's charts that identified changes in their conditions documented by HCAs; however there was no documented assessment or follow up by an LPN or RN to indicate that a nurse had assessed the person or took any actions. There is no system in place to monitor the person's progress notes to ensure that changes in their conditions are assessed and documented by a nurse. 2) A system has been put into place to ensure that persons in care are encouraged to be examined once a year by a dental health care professional. 3) A system has been put into place for persons in care to carry facility ID when they temporarily leave the facility. Each person in care has their own photo ID on a string at the front door that contains the facility's contact information. Families and employees have been educated that the person in care is required to take the ID with them when they leave the facility. 4) An employee is now attending the family council meetings, and the manager is following up on any action items as required.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  9. Routine Inspection

    16 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): There is no process in place to ensure that the representatives of persons in care are notified when there is a change in their condition, or if they experience an injury. Licensing Officer reviewed 3 charts and identified incidents where a person in care experienced a change in their condition or experienced an injury, and there was no documentation to indicate their representative had been notified. There is no process in place to ensure that reportable incidents are reported immediately to Licensing. Licensing Officer reviewed a person in care's chart and identified two incidents where the person in care was transported to hospital and neither incident was reported to Licensing, to the doctor, or to the funder. Licensing Officer requested the incident reports for these two incidents be submitted to Licensing. An incident of alleged abuse was not reported to Licensing until 8 days after the Manager was made aware of the alleged incident. There is no process in place to ensure that there is a record of all minor accidents, illnesses, and medication errors that are not reportable to Licensing. During discussions it was identified that employees are not consistently completing in-house incident reports for all medication errors, falls, changes in person in care's conditions and behaviours.
      • R4.5A - Immediately notify the parent, representative or contact person if a person in care becomes ill or injured while under the care or supervision of the licensee; 76 ( 1 )
      • R4.5B - Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77( 2 )(a)
      • R4.5C - Immediately notify the medical or nurse practitioner responsible for the person in care involved in a reportable incident; 77( 2 )(b)
      • 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)
      • R4.5E - Immediately notify the funding program, if any, if a person in care is involved in a reportable incident; 77( 2 )(d)
      • R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(a)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): There is no process in place to ensure that the monitoring of persons in care while in restraints is conducted and documented. Licensing Officer reviewed the restraint monitoring documents at 1430 and there was no documentation for the monitoring of the persons in their restraints since 0630.
      • R10.4C - Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
    • RB1.8 - Is there access to a fair, prompt and effective process to express concerns, make complaints or resolve disputes within the facility?
      • Observation(s): Please see comments in the report.
    • RB1.10 - Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
      • Observation(s): Please see comments in the report.
    • RB1.18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): Please see comments in the report.
    • 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): Please see comments in the report.
    • RB1.24 - Are persons in care or their representatives participating in the development and implementation of care plans?
      • Observation(s): Please see comments in the report.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): There is no process in place to ensure that there is regular monitoring of the care and services that are provided to persons in care. This is evident by the number of contraventions noted in this report.
      • 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): There is no process in place to express concerns, complaints and for dispute resolution. There is no process in place for the monitoring of employees to ensure the facility's policies and procedures are implemented. Licensing Officer reviewed 3 persons in care's charts who had experienced a recent fall, and it was identified that the employees did not follow the facility's falls policy. Upon hire employees are not orientated to The Residential Care Regulation and The Community Care and Assisted Living Act. Two members of the leadership team were not orientated to the legislation upon hire.
      • 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): There is no process in place to ensure that the performance of each employee is reviewed regularly. There is no documented evidence of probationary performance appraisals having been completed for employees hired in 2017, 2018, and 2019. The Manager who is responsible to manage unusual situations and emergencies is frequently absent from the facility and unavailable to guide the employees. There is no process in place to ensure that an employee who holds a valid first aid certificate is available to persons in care at all times. Licensing Officer inquired about the process for monitoring the expiry dates of employee's first aid certificates. It was recently identified that there was no process in place for the monitoring of expired first aid certificates and only 3 employees had current first aid certificates. Once this was identified a first aid course was organized for employees in May. Licensing requested, received, and approved a Health and Safety Plan for ensuring an individual with a current first aid certificate is immediately available to the persons in care at all times. There is no process in place to ensure that all employees involved in the preparation and delivery of food have the necessary training. Licensing Officer inquired about the process in place for the monitoring of food safe certificates for expiry dates. It was identified that in 2018 employees were required to refresh their food safe certificates and obtain one with an expiration date, however this was not completed. The site has since researched the refresher program and set up a sign-up sheet for those that have not completed this requirement.
      • 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)
      • R3.1N - Designate an employee qualified by training and experience to supervise employees who provide care to persons in care, coordinate and monitor the care of persons in care and manage unusual situations or emergencies; 41( 2 )(a)(b)( c)
      • 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)
      • R3.1Q - Ensure employees responsible for the preparation and delivery of food have the necessary experience, competence and training to ensure that food is safely prepared and handled, and meets the nutrition needs of persons in care; 44 ( 1 )(a)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The process in place to ensure that persons in care's monthly weight is recorded in their chart is ineffective. Licensing Officer reviewed 3 charts and found multiple months that the persons in care's weight were not recorded.
      • 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)
    • R4.6 - Are facility records current and complete?
      • Observation(s): There is no process in place to ensure menu substitutions are being recorded. Licensing officer reviewed the menu substitution binder and observed in 2018 menu substitutions were documented weekly, however the last recorded menu substitution was in April 2018.
      • R4.6C - Retain food services records of menus and menu substitutions; 87(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): There is no process in place to ensure persons in care who request a lock on their door and are suitable for same are provided one. There is no safe and secure place provided to persons in care to store their valuables.
      • R7.1U - Ensure that the entrance to the bedroom can be locked from the inside if requested by a person in care, unless it would be unsuitable given the health and safety needs; 26 ( 3 )
      • R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 1 ) (a)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): There is no process in place for the monitoring of the expiration dates on medications. Licensing Officer reviewed the last 2 Medication Safety and Advisory Committee meeting minutes and it was noted at both inspections that the pharmacist located several medications past expiry date.
      • R9.1I - Medications must be returned to the dispensing pharmacy if the person in care is no longer taking the medication or if the medication has expired; 72(a)(b)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There is no process in place to regularly monitor the persons in care to determine if their needs continue to be met. Licensing Officer reviewed 3 persons in care's charts and identified incidents where persons in care experienced a significant change in their condition and there was no nursing assessment or follow up documented. There is no process in place to encourage persons in care to be examined by a dental health professional at least once a year. Within the last year a dentist attended the site to provide dental services to persons in care, however there is no process in place to ensure that there is documented evidence for the persons in care who were offered the services, if they accepted or refused the services. There is no process in place to ensure that persons in care who temporarily leave the facility have facility identification in their possession. There is no process in place for the Licensee to meet with the Resident and Family Council to promote the collective and individual interests of the persons in care. The Resident and Family Council have been conducting monthly Council meetings, however the Licensee has not attended any of the meetings nor have they arranged to meet with the Council.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • R10.2H - 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 )
      • R10.2S - Provide at least an annual opportunity for councils, or if no council is established, as a group, to meet with the licensee to promote the collective and individual interests of the persons in care and involve the persons in care in decision making on matters that affect their day to day living; 59(b)(i)(ii) (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): There is no process in place to ensure that persons in care have oral care plans. There is no process in place to ensure that persons in care have a recreation and leisure care plan. There is no process in place to ensure that when a person in care experiences a substantial change in their condition or behaviour their care plan is updated to reflect the changes. In review of a person in care's chart it was identified that their mobility had significantly changed, and it was not reflected or planned for in their care plan.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
      • 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. Monitoring

    4 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): October 12, 2017 - The facility's process for ensuring persons in care comply with the Province's immunization program is ineffective. Persons in care who were admitted to the facility from July 2017 to present do not have immunization screening in place, as the employee who conducts the screening has been away.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): October 12, 2017 - The facility's process for ensuring compliance with the monthly weighing, and recording of each person in care's weight is ineffective. LO observed a chart of a person in care who was admitted to the facility in the summer. The recorded monthly weights for the months of August and September were noted to be missing, and there was no documentation to indicate the PIC refused to be weighed.
      • 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)
    • R4.6 - Are facility records current and complete?
      • Observation(s): October 12, 2017 - The facility has a system in place to respond to complaints, however there is no record of the concern that was brought forward and the facility's responses to it.
      • 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): October 12, 2017 - UNRESOLVED - The facility does not have a system in place to ensure compliance with persons in care being able to lock their bedroom doors should they choose to.
      • R7.1U - Ensure that the entrance to the bedroom can be locked from the inside if requested by a person in care, unless it would be unsuitable given the health and safety needs; 26 ( 3 )
  11. Monitoring

    10 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): February 22, 2017 - The facility's system to ensure compliance with monitoring of the MARs, to ensure they have employee initials, and PRN effectiveness documented for medications administered is ineffective. LO reviewed two MARs and found employee initials to be missing for routinely administered medications. LO reviewed the MARs and found that the PRN effectiveness is not consistently documented for PRN medications that are administered.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
      • R4.2E - Keep records of compliance with section 70 (administration of medication); 89( 2 )(d)
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): February 22, 2017 - The facility does not have a system in place to ensure compliance with maintaining furniture used by persons in care in a safe and clean condition. LO observed chairs in the lounge area of the locked units to be soiled and in need of cleaning. The housekeeping supervisor stated that an employee had reported the chairs required cleaning, however there was no plan in place for the cleaning of the chairs.
      • R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(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?
      • Observation(s): February 22, 2017 - The facility does not have a system in place to ensure compliance with each person in care having a nutrition plan in place that assesses the nutrition status, and specifies the nutrition to be provided. LO reviewed six persons in care's charts, and found two charts did not contain a nutrition assessment or nutrition care plan. Two charts contained a nutrition assessment and nutrition plan that was dated 2015.
      • 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): February 22, 2017 - The facility does not have a system in place to monitor the physical environment of the facility. LO observed tub rooms containing unlabeled personal hygiene products (UNRESOLVED). The facility is not monitoring the storage of cavi wipes (hazardous product). LO observed chairs in the lounge area to be soiled and require cleaning. The facility is not monitoring the MARs for initials of employees administering routine medications or for documented effectiveness of PRNs administered.
      • 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): February 22, 2017- UNRESOLVED- since December 2014 - The facility's system to ensure compliance with regular employee performance review is ineffective. The Manager stated that she has completed performance reviews for all regular fulltime, part time staff and regular casuals. Performance appraisals are still outstanding for employees who have been hired within the last 6 months, and the casuals that don't work often or work causal weekends still.
      • 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)
    • R4.6 - Are facility records current and complete?
      • Observation(s): February 22, 2017 - UNRESOLVED - The facility has a system in place to ensure compliance with the monitoring of food services and nutrition care, however they are not following the system that has been put into place. The facility submitted a compliance plan on May 30, 2016 that stated the facility would start an auditing system that would begin by June 30, 2016. During this inspection the blank audit sheets were shown to LO, and the foods manager stated that they have not yet completed any of the audits. The facility does not have a system in place to ensure compliance with employees keeping a record of menu substitutions. The employees are not recording the menu substitutions that are made.
      • R4.6C - Retain food services records of menus and menu substitutions; 87(b)
      • R4.6D - Retain the results of monitoring of food services and nutrition care; 87(c)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): February 22, 2017 - UNRESOLVED - The facility does not have a system in place for monitoring the tub rooms for compliance with the labelling of persons's in care's personal hygiene products. During inspection both tub rooms were noted to have unlabelled combs, hair brushes, hair rollers, nail brushes and nail clippers. The facility does not have a system in place to ensure compliance with outbreak prevention. Upon entry into the facility there is a small sign posted on the right wall stating it is flu season. It is next to the hand sanitizer, and a box of masks are sitting on the heat register below. LO had to search for flu season information, as it was not posted in a prominent area. The manager stated that the facility had ordered large standing influenza sign last month.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
      • R6.3F - Develop general facility outbreak prevention and control policies as recommended by the medical health officer; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): February 22, 2017 - The facility does not have a system in place to ensure compliance with persons in care being able to lock their bedroom doors should they choose to. The persons in care's bedroom doors do not have locking handles. The facility does not have a system in place to ensure the compliance with securely storing hazardous materials and not accessible to persons in care. LO found unlocked doors to two rooms that the manager stated should have been locked . The two rooms had cavi wipes sitting on the counters leaving hazardous items accessible to persons in care. The servery door was found to be unlocked. Upon questioning the manager stated that it was required to be locked at all times. This was resolved during inspection.
      • R7.1U - Ensure that the entrance to the bedroom can be locked from the inside if requested by a person in care, unless it would be unsuitable given the health and safety needs; 26 ( 3 )
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): February 22, 2017 - UNRESOLVED- The facility does not have a system in place to encourage persons in care to be examined by a dental health care professional at least once a year. The facility assists persons in care to see a dentist for dental emergencies.
      • R10.2H - Encourage persons in care to be examined by a dental health care professional at least once every year; 54( 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): February 22, 2017 - The facility does not have a system in place to ensure compliance with each person in care having a nutrition plan in place that assesses the nutrition status, and specifies the nutrition to be provided. LO reviewed six persons in care's charts, and found two charts did not contain a nutrition assessment or nutrition care plan. Two charts contained a nutrition assessment and nutrition plan that was dated 2015.
      • 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)
      • R10.3P - Develop, with the assistance of a dietician, a nutrition care plan for each person in care and review the plan with a dietician on a regular basis (Applies to a facility with 24 or more persons in care); 83( 2 ), 83( 3 )(b)
  12. Monitoring

    12 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): May 17, 2016 - UNRESOLVED - The facility's system to ensure compliance with documentation in the MARs is ineffective. The MARs inspected were missing staff initials for routine medications administered. Also missing was consistent documentation for effectiveness of the PRNs administered.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): May 17, 2016 - The facility's system to ensure compliance with having an up to date record of persons in care immunization status is ineffective. Two persons in care's charts reviewed did not contain up to date immunization documentation.
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): May 17, 2016 - The facility's system to ensure compliance with monitoring of the furniture used by persons in care is ineffective. The facility has 3 leather recliners and a leather couch that are worn leaving the chair porous and unable to be sanitized properly. The leather couch had a large hole in the lower portion of the couch. At the time of the inspection this damaged furniture was not scheduled for repair or replacement.
      • Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • 13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): May 17, 2016 - Recreation care plans do not consistently meet all person in care's needs. LO reviewed recreation care plans that stated person in care does not like facility planned activities. The care plan did not address how his needs would then be met.
      • Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
    • 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): May 17, 2016 - Recreation care plans do not consistently meet all person in care's needs. LO reviewed recreation care plans that stated person in care does not like facility planned activities. The care plan did not address how his needs would then be met.
      • 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.
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): May 17, 2016 - UNRESOLVED - The facility's system to ensure compliance with regular performance reviews conducted for each employee is ineffective. The facility manager stated that the employee performance reviews are 75% completed.
      • 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)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): May 17, 2016 - The facility's system to ensure compliance with persons in care being weighed and recorded monthly is ineffective. Two persons in care's charts were reviewed and the last documented weight was in January 2016.
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 4.6 Are facility records current and complete?
      • Observation(s): May 17, 2016 - The facility's system to ensure compliance with monitoring of the food and nutrition services is ineffective. The food service manager reported to LO that the facility is not currently auditing food quality or food service. May 17, 2016 - The facility's system to ensure compliance with retaining a record of concerns brought forward is ineffective. The facility does not have a record of the concerns brought forward and their responses to them.
      • Retain the results of monitoring of food services and nutrition care; 87(c)
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): May 17, 2016 - The facility's system for ensuring compliance with assisting persons in care in maintaining health and hygiene is ineffective. In a tub room LO located unlabelled nail clippers, scissors, tweezers, nail files, brushes, combs and multi use hair rollers.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): May 17, 2016 - The facility's system to ensure compliance with proper storage of hazardous materials is ineffective. The hopper room has a metal sliding lock that opens easily thus the room is accessible to persons in care. Sharp metal nail files and sharp scissors were found in the unlocked tub room thus leaving sharp items accessible to persons in care.
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): May 17, 2016 - The facility's system to ensure compliance with the monitoring of each person in care to ensure their needs continue to be met is ineffective. LO reviewed nursing notes that stated a person in care had an incident. LO was unable to locate follow up documentation to indicate the doctor and the family had been notified, or that the care plan was reviewed and/or updated. LO unable to locate a documented nursing assessment following the incident. May 17, 2016 - The facility does not currently have a process in place to encourage persons in care to be examined by a dental health care professional at least once a year. The facility assists persons in care if a dental emergency occurs.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • Encourage persons in care to be examined by a dental health care professional at least once every year; 54( 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): May 17, 2016 - The facility's system to ensure compliance with behavioural care plans including interventions to guide the staff is ineffective. The behaviour care plans reviewed did not consistently include information to guide the staff in behavioural interventions. May 17, 2016 - The facility's system to ensure compliance with recreation and leisure care plans to guide the staff is ineffective. The recreation care plans reviewed did not include resident's recreation goals, nor did they include a plan for the residents who do not enjoy large group or facility planned activities.
      • Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • Care plans must include a recreation and leisure plan; 81( 3 )(d)
  13. Monitoring

    10 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Unresolved from previous inspection - The facility continues to under report. Improved policy and procedure for reporting reportable incidents to Licensing is required. Staff are required to be trained on facility incident reporting procedures. Facility will be sent a progressive compliance letter requesting health and safety measures regarding this infraction as it is considered high risk and has not been resolved from the previous inspection.
      • Ensure there are written policies and procedures regarding responding to reportable incidents; 85( 2 ) (j)
    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Unresolved from previous inspection - PRN effectiveness is not consistently charted in MAR. Missed initials found in MAR's for routine medication. Facility will be sent a progressive compliance letter requesting health and safety measures regarding this infraction as it is considered high risk and has not been resolved from the previous inspection.
      • 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): Unresolved from previous inspection - The facility is not reporting all reportable events in Schedule D of the Residential Care Regulation to Licensing. Facility will be sent a progressive compliance letter requesting health and safety measures regarding this infraction as it is considered high risk and has not been resolved from the previous inspection.
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
      • Immediately notify the funding program, if any, if a person in care is involved in a reportable incident; 77( 2 )(d)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Unresolved from previous inspection - Evidence not available on site that employees have continued compliance with the provinces immunization and TB control programs. Facility has information for newly hired staff but does not have information for long term staff.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Unresolved from previous inspection - PIC washrooms and public washrooms in the multi care unit do not have call bells. This item has been noted on consecutive inspections and has not been resolved; submit a H&S plan to Licensing on how PIC's are monitored in washrooms until call bells are installed, the plan will also indicate the date in which all washrooms will have call bells installed. Facility will be sent a progressive compliance letter requesting health and safety measures regarding this infraction as it is considered high risk and has not been resolved from the previous inspection.
      • Provide a monitoring system or signalling device that will signal that a person in care needs immediate assistance; 19( 1 )(c)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Unresolved from previous inspection - facility indicates the last routine/monitoring inspection was posted but it was not posted at the time of this inspection. Ensure area where inspection is posted is monitored on a regular basis to ensure the report has not been removed. Unresolved from previous inspection - facility indicated they were not sure what charting of self-monitoring would look like, Licensing discussed expectations of self monitoring documentation with the facility manager during this inspection. Facility will be sent a progressive compliance letter requesting health and safety measures regarding this infraction as it is considered high risk and has not been resolved from the previous inspection.
      • 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)
      • Regularly monitor the physical environment and the care and services provided; 61
    • 17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
      • Observation(s): The most recent routine/monitoring inspection was not posted in a prominent place at the time of this inspection.
      • Post the most recent routine inspection in a prominent place.
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Unresolved from previous inspection - Facility has begun to chart in a flow sheet personnel information for newly hired staff however the information for existing staff is unavailable for review, ensure a charting process is place the details staff requirements. Unresolved from previous inspection - Staff performance evaluations are taking place but they are still not up to date, facility goal is to have a performance evaluation every three years. Facility will be sent a progressive compliance letter requesting health and safety measures regarding this infraction as it is considered high risk and has not been resolved from the previous inspection.
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): Unresolved from previous inspection - Staff files not kept on site, there is no process in place to indicate that all required documents have been obtained for each staff member.
      • Keep employee criminal record check results; 86(a)
      • Keep employee character references; 86(b)
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Unresolved from previous inspection - Lounge area has several chipped walls requiring paint and door frames throughout the building are damaged and require repair and paint. Servery door unlocked at time of inspection, resolved during inspection. Two propane tanks stored in outdoor activity area during this inspection, ensure all potentially hazardous materials are kept 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)
  14. Monitoring

    19 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Dec 17, 2014 - UNRESOLVED -Falls policies do not include written plans for responding to a fall suffered by a resident. Including the steps taken to ensure assessing the ongoing health and safety of the Resident who has fallen and how to mitigate the risk for subsequent falls. May 11, 2015 - UNRESOLVED - The facility continues to under report. Improved policy and procedures for reporting reportable incidents to licensing is required. Staff are required to be educated on the policy for reportable incidents.
      • 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)
      • 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).
      • Ensure there are written policies and procedures regarding responding to reportable incidents; 85( 2 ) (j)
    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): May 26, 2014-UNRESOLVED - PRN effectiveness is not consistently documented on the MAR. May 11, 2015 -Initials found missing from MARs for routine medications administered.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): May 11, 2015 - Unable to locate restraint care plans, and routine monitoring for the resident's who use restraints.
      • Record the type or nature of the restraint used in the person's care plan; 84(a)
      • Record the reason for the use of restraint in the person's care plan; 84(b)
      • Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • 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)
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
      • Keep a record of employee compliance with the requirements of Division 5 (Use of Restraints) of Part 5 in the persons care plan; 84 (f)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): May 11, 2015 - The facility is not reporting all reportable events in schedule D of the Residential Care Regulations to licensing. The manager states the facility is reporting falls that lead to a ER visit and all deaths in the home, however they have not been reporting all unexpected illnesses that result in a transfer to ER.
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
      • Immediately notify the funding program, if any, if a person in care is involved in a reportable incident; 77( 2 )(d)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): May 11, 2015 - See previous comments in 4.4 regarding staff files.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 5 )
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): May 11, 2015 - Unable to locate immunization screening and TB screens in Resident's charts.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 5 )
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
      • Provide information to persons in care regarding the benefits of immunization including pneumococcal, annual influenza and tetanus-diphtheria if appropriate; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Dec 22, 2014 - UNRESOLVED - Resident washrooms and public washrooms in the multi care unit of the building do not have call bells. The rooms are wired for call bells but they have not been attached. Ensure each washroom has a call bell available for the Resident's to alert staff immediately when they require assistance.
      • Provide a monitoring system or signalling device that will identify the location of the person in care; 19( 1 )(b)
      • Provide a monitoring system or signalling device that will signal that a person in care needs immediate assistance; 19( 1 )(c)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): May 11, 2015 - Unable to locate restraint care plans for the Resident's who use them. Unable to locate documentation for the reassessment of the restraint. Unable to locate doctor orders and family written consent for all restraints in use. Unable to locate on going monitoring of the resident during the use of the restraint.
      • Ensure a restraint is not used unless necessary to protect the person in care or others from serious physical harm; 73 ( 1 )(a)
      • Ensure a restraint is not used unless it is as minimal as possible, taking into consideration both the nature of the restraint and the duration for which it is used; 73( 1 )(b)
      • Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
      • Ensure all alternatives to the use of a restraint have been considered and either implemented or rejected; 73( 2 )(a)
      • Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
      • Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
      • Provide in the care plan a plan to address, if there is agreement to the use of restraints, the type or nature of restraint and the frequency of reassessment; 81( 3 )(a)(iii)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Dec 17, 2014 - UNRESOLVED - The facility is not self monitoring the care and services it provides. The manager reports that the facility has developed some audits and checklists to assist them to self monitor however they are not consistently being completed and assessed for compliance. May 11, 2015 - The most recent inspection report was not displayed at time of inspection. The manager printed the December 17, 2014 report and posted it during this inspection.
      • 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)
      • 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): May 11, 2015 - The facilities complaint process requires improvement. There is no written information given to families upon admission explaining how to express a concern or make a complaint within the facility. The facility does not have a complaint log in place nor are they documenting the responses to the concerns and complaints that are brought forward.
      • Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(a)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): May 26, 2014 - UNRESOLVED - Inadequate performance evaluations of all staff. Dec 17, 2014 - UNRESOLVED - The manager does not have any staff files or staff documents on site. LO discussed creating a flow sheet to check off all staff file requirements and indicate on the flow sheet the documentation that staff bring in. The Manager was unsure if the staff first aid certificates had expired or were still valid. May 11, 2015 -UNRESOLVED- Staff performance appraisals remain outstanding. The Manager has completed 5 in the last month. - The fire drills are not conducted on evening shifts or night shifts. There is currently no plan in place for educating or assessing the night staff's knowledge of the facility emergency plan.
      • Obtain character references for all employed persons; 37( 1 )(b)
      • Obtain a record of work history for all employed persons; 37( 1 )(c)
      • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37( 1 )(d)
      • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
      • 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)
      • 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)
      • Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 7 )
      • 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)
      • Keep all criminal record check results and character references for other persons for the entire time that the subject of the criminal record check or character reference is ordinarily present on the premises; 92( 3 )(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): May 11, 2015 - Unable to locate admission date, weight and height in several resident's charts. -Two units at the facility have the Resident's charts accessible to anyone in the unit including visitors.
      • Record the height and weight of each person in care on admission; 49 ( 6 )
      • Keep for each person a record showing the date of admission to the facility; 78( 1 )(b)
      • 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
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): May 11, 2015 - The facility does not have staff files on site. There is no process in place to indicate that all required documents have been obtained for each staff member.
      • Keep employee criminal record check results; 86(a)
      • Keep employee character references; 86(b)
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 4.6 Are facility records current and complete?
      • Retain food services records of menus and menu substitutions; 87(b)
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 5 )
      • Retain records of complaints for at least 2 years; 92 ( 10 )
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): May 11, 2015 - Snacks are not documented on the 4 week menu.
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )( c)(i)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): May 11, 2015 - Unable to locate fridge temperature logs for the fridges on the units. -Unlabelled nail files, nail clippers, nail brushes, hair brushes, and combs found in the tub room.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 5 )
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 5 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): May 11, 2015 - Each week of the 4 week menu was posted however there was nothing indicating what day and week of the menu it was. -Resident's charts accessible as not in locked cupboards, or stored behind a locked door. -Tub room was found unlocked with hazardous materials accessible to Residents. -Lounge area has several chipped walls requiring paint. -Door frames throughout the building are damaged and require repair and paint.
      • 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)
      • Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 8 )
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): May 11, 2015 - The facility does not consistently ensure that all Residents who leave the facility temporarily have facility ID on them.
      • 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 ) ( 22 )
    • 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): May 11, 2015 - Care plans are inadequate and are missing detailed Resident specific information.
      • Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • Care plans must includes an oral health care plan; 81( 3 )(b)
      • Care plans must include a recreation and leisure plan; 81( 3 )(d)
      • Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  15. Monitoring

    7 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Fall prevention procedures do not include written plans for responding to a fall suffered by a person in care, including steps to be taken to ensure the health and safety of the person in care who has fallen and to prevent subsequent falls by the person in care. Please ensure fall prevention policies are updated to include written procedures for staff to follow post fall.
      • 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).
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): At the time of this inspection information regarding which staff have not received a flu shot and would require a mask was not available to the supervising staff, this information was only available to the Manager who was not present. Develop a procedure that ensures supervising staff are aware of which staff are required to wear a mask.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 (11)
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): PIC washrooms and public washrooms in the multi care unit portion of the building do not have call bells. The rooms are wired for call bells but they have not been attached. Ensure each washroom has a call bell available for PIC's to alert staff when they require assistance.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing inspection posted near entrance is from December 2010, the most recent licensing inspection is posted in an area of the building where staff have access, ensure the most recent inspection is posted in an area where visitors can easily view. This infraction has been noted on consecutive licensing inspections. Inadequate self monitoring procedures was noted during the last licensing inspection in May 2014, Licensing unable to view documentation as Manager not present during this visit, infraction will be left open to be viewed at a later date.
      • 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)
      • Regularly monitor the physical environment and the care and services provided; 61
    • 17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
      • Observation(s): Most recent licensing inspection is posted in a staff area of the building, ensure the most recent inspection is posted in an area which is accessible to visitors.
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Inadequate performance evaluations of staff noted on last licensing inspection in May 2014, Licensing unable to view during this inspection as manager not available, this infraction will be left open to be followed up on at a later date. Documentation of staff training noted on the last Licensing inspection in May 2014, Licensing discussed how the facility Manager could track staff documentation locally as actual documents are stored with HR, not able to view local tracking documentation as Manager not available. These infractions will be followed up at a later date.
      • Ensure criminal record checks are obtained for all employed persons; 37(1)(a)
      • Obtain character references for all employed persons; 37(1)(b)
      • Obtain a record of work history for all employed persons; 37(1)(c)
      • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37(1)(d)
      • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37(1)(e)
      • 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)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Ensure all persons in care who can leave the facility on their own carry identification and have a care plan which documents specifics regarding: how long they are able to leave and steps staff should take if they do not return on time.
      • 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)