Good Samaritan Canada Heron Grove
4900 20 St Vernon BC V1T 9W3 · Residential Care - Licensing
15 inspections
- Routine Inspection
2 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): The system to ensure that Medication Administration Records (MAR) show all medications administered is in effective as evident by missed signatures. Failure to complete MARs as required could pose a significant risk to persons in care compromising safety and continuity of care. This has been a repeated contravention over the past three routine inspections. Submit by November 21, 2025, the plan that will be implemented to ensure ongoing compliance with Section 78(2)(a) of the Residential Care Regulation.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The system for maintaining the physical environment in a good state of repair is ineffective as observed by excessive wheelchair marks, dents and wall damage and in need of painting in a person in cares bedroom. Regular maintenance is important to ensure the ongoing health, safety and dignity of persons in care. Submit by November 21, 2025, the plan that will be implemented to ensure ongoing compliance with Section 22(1)(b) of the Residential Care Regulation. The system to ensure that all rooms and common areas are maintained in a safe and clean condition is ineffective as observed by a door to the Kitchen area left opened and unattended. It was also observed that the general cleanliness of fridges having not been cleaned. Not maintaining safe and clean conditions poses a risk to the health and safety of persons in care. Submit by November 21, 2025, the plan that will be implemented to ensure ongoing compliance with Section 22(1)(c) of the Residential Care Regulation.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
4 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): The system to ensure that Medication Administration Records show all medications administered is in effective as evident by missed signatures. This contravention was also noted on the last routine inspections.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): The system to ensure that all policies and procedures are followed is ineffective. A review of the room temperature checklists identified missing daily checks. It was observed that a bath / shower temperature checklist was last signed off on August 11th.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): The system to ensure monthly weights are recorded is ineffective, it was observed that a monthly weights checklist had missed recordings.
- R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): The system to ensure ongoing tray service is reassessed at least once every 30 days was ineffective. During a chart review it was noted that renewals were not signed by the medical or nurse practitioner. This contravention was also noted on the last two routine inspections.
- R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
5 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): The system to ensure that Medication Administration Records show all medications administered is in effective as evident by missed signatures.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
- Observation(s): The system to ensure ongoing planned program of physical, social and recreation activities is in effective. Recreation calendars were noted with minimal or no activities taking place.
- 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)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The system for self-monitoring was ineffective as noted by the following deficiencies that were observed; Hight touch cleaning checklist, Resident daily temp checklist, Bath / shower checklists and Fridge / Freezer temperatures were sporadically missing signatures. It was also observed that a ‘MY Day’ in a person in care’s bathroom was not updated to reflect the current Care Plan.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The system for self-monitoring the physical environment is ineffective as noted by the observed deficiencies; Patio furniture not cleaned, Paint peeling off Patio door and frame, Water leak on exterior wall, Cobwebs covering patio door and exterior wall Excessive wheelchair marks on Interior walls Ceiling area around fans not cleaned in some time. The system to ensure that staff are not smoking on the premises is ineffective. Cigarette butts were observed on the outside patio next to a staff members lunch cooler. The system to ensure that the weekly menu is posted in a prominent place was in effective, there was no posted weekly menu.
- R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
- R7.1M - Ensure that no one other than a person in care engages in a restricted activity while on the premises of the facility; 23(2)(a).
- R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): The system to ensure persons in care regularly receive a bath or shower is ineffective. It was observed that several baths times had been missed without making-up resulting in unsatisfactory delays between bath times. The system to approve, and reassess ongoing tray service is ineffective. In review of person in care's records there was no documented evidence of reassessment for ongoing tray service as required. This was also a contravention on the last routine 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 )
- R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
8 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): The system to ensure medication administered is recorded is ineffective. A review of the MAR's identified several medications not recorded showing the date, amount and time as prescribed.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): The system to monitor and record the person in care as per the care plan is ineffective. It was identified that restraint monitoring records were incomplete. This was also noted as a contravention on the last routine inspection.
- R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): The system to ensure Immediate notification to Licensing is ineffective as a review of Care plans identified a reportable incident which was not reported.
- 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): The system to ensure compliance with policy is ineffective. A review of the MAR's identified several PRN effectiveness not charted as per policy.
- R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): The system to ensure that each person in care is weighted at least once per month is ineffective as indicated by sporadic charting.
- R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): It was observed that person in care's bedrooms did not contain a secure place to store valuables. This was also noted as a contravention on the last routine inspection.
- R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 1 ) (a)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): The system to ensure call bell monitoring is ineffective as evidenced by incomplete charting. The system to ensure tray service is reassessed at least once every 30 days is ineffective. A tray service agreement was not reviewed monthly as per policy.
- R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
- R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): It was identified in a care plan that person in care would receive 1:1 visits with a member of the Recreation team at least once per week. There was no documented evidence to suggest this was implemented.
- R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
4 infractions
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): Restraint Monitoring documentation indicating the type, frequency and monitoring of the restraint were incomplete.
- R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): The system to ensure persons in care or their representative that would like to express concerns or make complaints to Licensing is ineffective. This was also a contravention during a Routine Inspection in November 2020. Facility currently has a draft version of a new Resident Handbook and a new information poster was produced after this Inspection. It was observed a binder containing medication policy and procedures were outdated. Evidence was produced that newly revised polices and procedures will replace the outdated binder.
- R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
- R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
- R4.6 - Are facility records current and complete?
- Observation(s): Resident Photo Report Information Sheets were incomplete.
- R4.6L - Ensure all records are current; 91( 1 )(a)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Ceiling light fixture had no cover exposing wires. (This was corrected during the inspection.) Door to tub room was found unlocked and accessible to persons in care. It was observed that person in care's bedrooms did not contain a safe, secure place to store valuables. There are no covered areas from inclement weather in the outdoor space for each cottage.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 1 ) (a)
- R7.1AN - Provide outside activity areas that have comfortable seating including a reasonable amount of shelter from sun and inclement weather; 36 ( 1 ) (c)
- R4.3 - Is documentation concerning restraints adequate?
- Substantiated complaint
3 infractions
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): The complainant alleges non-compliance with monitoring, signalling and communication in relation to call bells for persons in care to communicate to staff not operational and placed out of reach for persons in care to use. Licensing reviewed policy, maintenance records and person in care charting. Licensing notes evidence of non-compliance in providing persons in care with functional communication devices and there to be no system in place to ensure the placement of the call bells is appropriate for persons in care. Licensing determines the complaint to be SUBSTANTIATED. As a result of this complaint, policy and procedure was reviewed by facility leadership and a revised emergency call bell procedure and monitoring system were developed, implemented and submitted to Licensing for review prior to completion of this report. All person in care's care plans have been revised to include appropriate placement of call bells. Licensing accepts the non-compliance as resolved.
- R7.2H - Provide communication devices and other means of communication that are appropriate to the needs of persons in care; 19( 2 )(a)
- R7.2I - Provide communication devices and other means of communication that enable persons in care to communicate their needs to employees; 19( 2 )(b)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): The complainant alleges non-compliance with dispute resolution, specifically complaints, in relation to a catheter used for a person in care, are not responded to or addressed promptly. Licensing reviewed complaint records which contain receipt of concern, actions taken and response to complainant which complied with the facility complaint policy. Licensing determines the complaint to be UNSUBSTANTIATED. As a result of the complaint investigation, Licensing notes policies and procedures have not been reviewed at least once per year. This contravention is subsequent to the complaint allegations. As a result of the complaint investigation, Licensing notes facility policy: Contingency Plan for Interruption of Service: Nurse Call Systems as not implemented by employees. This contravention is subsequent to the complaint allegations.
- R2.1L - Respond to all complaints, concerns, disputes promptly. 60(c)
- R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): The complainant alleges non-compliance with implementation of care plans, specifically, in relation to falls and call bell placement and the use of compression stockings for a person in care. Licensing reviewed person in care's care plans and charting and notes evidence of non-compliance with the implementation of care plans. Licensing determines the complaint to be SUBSTANTIATED.
- 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
- R7.2 - Is the environment maintained to prevent falls?
- Substantiated complaint
1 infraction
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): The complainant expressed a concern that on March 31, 2022 wound care was not provided as per the care plan. Information gathered confirmed wound care was not provided as directed in the care plan. Licensing finds this complaint SUBSTANTIATED.
- R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Routine Inspection
0 infractions
- Routine Inspection
7 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Upon review of several Medication Administration Records (MARs), it was noted that the system in place for medication administration is ineffective. On several MARs for different persons in care, missed signatures are repeatedly seen with no documentation to support whether the medications were administered or not.
- 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): During the inspection, it was noted that the facility's self-monitoring processes are ineffective. In regards to post falls assessments, there is no auditing system in place to ensure that post-falls assessments are being conducted completely as per the site policy and procedure. In regards to the Medication Administration Record (MAR), the auditing system did not identify any action plan or follow-up beyond emailing the staff to notify them that they had neglected to document whether or not the medication had been given. There is no auditing system in place to ensure that "as needed" (PRN) medication effectiveness is assessed and documented.
- 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): Upon review of the Admission Handbook, it was determined that the system in place for the person in care, their parent or representative to express a concern or make a complaint to Licensing is ineffective. It was discussed that the changes made will be brought forward to all current persons in care, as well as their parent or representative. During the inspection, it was noted that the system in place to document post-falls assessments is ineffective. It was noted that the post-falls assessment sheets that were reviewed were not completed.
- R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Upon a sampling of person in care's medication administration records (MARs), the process for documenting "as needed" (PRN) effectiveness is ineffective. Multiple MARs are missing documentation pertaining to the effectiveness of the PRN medication.
- R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): The system in place to keep records and personal information of persons in care confidential is ineffective. On November 18, 2020, the day after the routine inspection, it was noted that between Nov 12-14, 2020, 3 Reportable Incidents to Licensing were wrongly forwarded to another Long Term Care Facility.
- R4.1S - Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
- R4.6 - Are facility records current and complete?
- Observation(s): The system in place for the Licensee to produce records to Licensing in a timely manor is ineffective. During 2 recent complaint investigations, the Licensee has failed to submit responses to Licensing when requested on multiple occasions.
- R4.6P - Produce records, on demand, to licensing; 91( 2 )(c)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): During the inspection, it was noted that the process in place to ensure that all medications are safely and securely stored is ineffective. Medicated cream was noted in one person in care's bathroom in an unsecured cabinet.
- R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
1 infraction
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): During the inspection, it was noted in a care plan and My Days that one person in care was wearing a positional belt that was care planned to be not a restraint and staff would not be following facility restraint monitoring policy. It was determined that this person in care has a Management Risk Agreement (MRA) with the facility and it is facility policy to review/revise this consent at least once per year. The MRA was last reviewed/revised in 2017.
- R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Monitoring
3 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): There is no system in place to ensure Licensing is notified of any structural change. It was noted during the inspection the facility installed a fixed cupboard in the lounge area in two of the cottages. The fixed cupboards may impede on the floor space required per each person in care. There is no system in place to ensure a health and safety plan was submitted and approved prior to any structural change. The cupboards were installed without notification to Licensing or approval by Licensing of the health and safety plan.
- R1.1B - Submit plans for the change to licensing and receive written approval prior to making any structural changes; 8( 2 )(a)(i)
- R1.1C - Submit health and safety plan to licensing and receive written approval prior to making any structural changes; 8( 2 )(a)(ii)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): There is no system in place to ensure emergency plans are updated with any change in the facility. It was noted during the inspection the emergency preparedness plans were not updated with the correct Residential Services Manager name and contact number. There is no system in place to ensure policies and procedures are reviewed once a year. It was noted during the inspection that the Emergency Preparedness manual had not been reviewed or revised in the last two years as the old Residential Service Managers name was still in place on the documents and the date on emergency preparedness polices was 2015.
- R2.1H - Update emergency plans if there is any change in the facility; 51 ( 2 )
- R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): There is no system in place to ensure the outside area is in safe condition. An electrical cord was laying on the patio and ground of one of the fenced outside areas during the inspection. The Manager immediately removed the cord and this item was corrected during the inspection.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Monitoring
2 infractions
- RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
- Observation(s): As previously mentioned in the inspection report: The system for ensuring compliance with modifying each care plan if there is a substantial change in the circumstances is ineffective. Several person in care records were reviewed during the inspection. One record indicated on the care plan that a specific restraint was being used, but in further review of the documentation, the consent form from the family had a written notation on it that the restraint had been discontinued in February of 2016. The care plan had just been updated in December of 2016 indicating the restraint was still in use. The Care Manager followed up with the staff during the inspection. The restraint is no longer being used and the care plan was updated during the inspection. This item was corrected during the inspection. (CDI)
- 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.
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): The system for ensuring compliance with modifying each care plan if there is a substantial change in the circumstances is ineffective. Several person in care records were reviewed during the inspection. One record indicated on the care plan that a specific restraint was being used, but in further review of the documentation, the consent form from the family had a written notation on it that the restraint had been discontinued in February of 2016. The care plan had just been updated in December of 2016 indicating the restraint was still in use. The Care Manager followed up with the staff during the inspection. The restraint is no longer being used and the care plan was updated during the inspection. This item was corrected during the inspection. (CDI)
- 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)
- RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
- Monitoring
4 infractions
- 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
- Observation(s): As noted previously in the inspection - several unlabeled toiletries were found in the tub rooms of several cottages. The manager removed these items and this was corrected during the inspection.
- Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
- 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Incomplete snack menu plan noted throughout the cottages. There was a menu plan posted but the snack menu only contained one choice of snack. There was a snack menu posted in several of the cottages but several snack choices were crossed off and the it was difficult to determine the choices of snacks available. This remains outstanding from the past inspection report.
- Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Damage to the walls noted in the lounge areas in several of the cottages. Carpet in the lounge areas in several of the cottages noted to be stained. Outside activity area in one cottage noted to have several items stored in the sheltered area and the area was not accessible by persons in care due to these items being stored.
- Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- Provide outside activity areas that have comfortable seating including a reasonable amount of shelter from sun and inclement weather; 36 ( 1 ) (c)
- 10.1 Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
- Observation(s): Several unlabeled toiletries were found in the tub rooms of several cottages. The manager removed these items and this was corrected during the inspection.
- Promote the health, safety and dignity of persons in care; CCALA 7( 1 )(b)(i)
- 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
- Monitoring
7 infractions
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): The Medication Administration Record for each of the six cottages was reviewed showing several missed signatures for regularly scheduled medications on each Medication Administration Record.
- Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- 7.2 Is the environment maintained to prevent falls?
- Observation(s): Garden watering hoses were left out on the patio area of two cottages. One hose was safely secured during the inspection. Several of the foam bath cushions used during baths were noted to be cracked and open areas exposing the foam noted by the suction devices. Some of the bath cushions were discarded during the inspection.
- Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
- Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
- 10.4 Are restraint and fall prevention plans appropriate?
- Observation(s): The Licensing Officer was provided with a restraint list of those persons in care who have restraints. The restraint for one person showed for regular monitoring on the care plan but this was not carried forward in the electronic daily monitoring plan. Although this particular record was corrected during the inspection, all of the records will need to be checked on those persons in care with restraints to ensure monitoring is captured on each of the daily monitoring plans on those persons in care with restraints in place.
- 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)
- 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): Property maintenance policies have not been reviewed for several years. Several other various policies were also noted as not being reviewed for several years. The facility will be going through Accreditation in October of 2015 and part of the Accreditation process is reviewing all of the policies and procedures. Fire drills were noted to be missed during the months of March, April and May of this year. The policy indicates that fire drills are to be conducted monthly. Fire drill for month of June has not taken place yet. Follow up date for this item is June 30, 2015.
- Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
- Ensure policies are implemented by employees; 85( 1 )(d)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): A sampling of staff records were reviewed during the inspection. One staff record was missing tuberculosis screening and another staff record was missing immunization screening. There was no evidence of performance evaluations available for the Licensing Officer to review during the inspection. The performance evaluations are kept in a separate file which the manager only has access to. The Care Manager provided a copy of a schedule of evaluations for the care staff which will be completed by Sept. 2015.
- 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)
- 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Menu plan in two cottages did not include snacks on the on the menu plan.
- 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)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): There was no evidence on record of Fire Inspections being completed at the facility. There was evidence that the sprinkler system had been professionally checked Nov. of 2014. The Care Manager stated that Fire Inspections are usually completed every October. A prescription treatment cream was found at the bedside of a person in care. The treatment cream was removed by the Care Manager during the inspection. This item was corrected during the inspection.
- Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 7 )
- Provide a safe and secure storage area for self-administered medications; 69( 3 )(b)(i)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
8 infractions
- 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): A sampling of records reviewed that one person in care record did not have a TB screen on file.
- Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 (11)
- 7.2 Is the environment maintained to prevent falls?
- Observation(s): One of the outside patio areas had a garden hose spread out to one of the raised garden beds and there was ice on the ground where the garden hose had leaked posing a tripping and slipping hazard. This was corrected during the inspection.
- Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
- 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): Policy on reportable incidents did not include the updated schedule D to include "aggression between persons in care".
- Review and, if necessary, revise policies and procedures at least once a year; 85(1)(b)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): A sampling of staff records were reviewed and one of the staff records contained an RCMP criminal record check. Criminal Record Checks must be completed by the Ministry. Performance reviews were not observed during this inspection.
- Ensure criminal record checks are obtained for all employed persons; 37(1)(a)
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): In one cottage during the inspection the medication administration record was found to be on top of the med cart accessible to passers by. This was corrected during the inspection.
- 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
- 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Snacks were not included on the menu plan posted in the dining rooms for each cottage.
- 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)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The alternate laundry door in one of the cottages was found to be unlocked and there was powder laundry detergent accessible to persons in care. This was corrected during the inspection.
- Ensure that laundry facilities if not used by persons in care, cannot be accessed by persons in care; 35(2)(b)
- 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Fingernail polish remover found in a bathroom cupboard of a person in care. This was removed during the inspection. It was also noted that there was personal cleaning supplies stored in the bathroom of a person in care requiring safe storage. This item requires follow up. One bathing room in one of the cottages noted to have a set of nail clippers, scissors and tweezers left on the counter unlabelled. Another bathing room in one of the cottages had a container with personal items such as combs, fingernail clippers and razors found stored together. These items were labelled with persons in care names but stored all together.
- Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 (11)
- 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?