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Good Samaritan Canada, Mountainview Village

3070 Burtch Rd Kelowna BC V1W 5G2 · Residential Care - Licensing

13 inspections

  1. Routine Inspection

    3 infractions

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It was observed that one of the outdoor patios had some napkins and other debris left in an area that is available for persons in care to use. Further discussion indicated that there was no system in place to ensure these areas are kept clean. If spaces are not kept clean, persons in care may feel a loss of dignity and be less likely to utilize these spaces, which are meant for enjoyment. When this was brought up, the debris was removed, and a system was verbally put into place for ongoing compliance. Submit to Licensing by November 12, 2025, a plan which details how all patio areas will be kept in a safe and clean condition. The plan must include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements. It was observed that a topical prescription cream was left, unsecured, in a person in care's room. Medications left unsecured in person in care's rooms may increase the risk of persons taking or applying medications without oversight and possibly incorrectly. Medications left out may also be ingested by persons in care. This was also a contravention on the March 2025 routine inspection report. Submit to Licensing by November 12, 2025, a plan which details how all medication will be securely stored. The plan must include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Care plans were reviewed, and it was noted that a person in care had an order for ongoing room tray service; however, the plan had not been reassessed since it was implemented in June 2025. Reassessment every 30 days is necessary to ensure that person in care does not have any new concerns that might make eating by room tray service unsafe. Submit to Licensing by November 12, 2025, a plan which details how all room tray service agreements will be reassessed as required. The plan must include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • 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): Care plans were reviewed, and it was noted that one person in care did not have a monthly weight routinely documented. It was discovered that this person in care refuses to have weights taken some months, but there was no documentation to reflect this. There was also nothing in the care plan to advise staff on how to monitor for any significant changes in weight. When a person in care is not weighed, it is important that the reason is documented to ensure that there is monitoring occurring despite the refusal. Ongoing monitoring is important to know when it is appropriate to seek advice if there is a significant change in weight. Submit to Licensing by November 12, 2025, a plan which details how it will be documented in the care plan the reason that a person in care has not been weighed. The plan must include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R10.3S - Record in the nutrition plan the reason why a person in care has refused or is unable to be weighed and that immediate advice is sought of a health care provider when it appears that a person in care may have experienced a significant change in weight; 83( 5 )(a) (b)
  2. Routine Inspection

    6 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The Licensee's system for ensuring restraints are monitored while in use was found to be ineffective. During the inspection, restraint monitoring documentation was reviewed, and it was observed that in three instances, documentation was not being done at the time of monitoring.
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The Licensee's system to ensure the simplified care plans in each person in care's room are updated to reflect the most current version was found to be ineffective. During the inspection, person in care's rooms were observed. In one room it was noted that the posted plan was not the most recent version. In a second room there was no plan posted.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The Licensee's system to ensure refrigerator temperature checks are completed as required was found to be ineffective. During the inspection, refrigerator temperature monitoring sheets were reviewed and it was noted that two refrigerators were missing multiple checks. In one instance, the second check had not been completed for six days in a row. This was also noted as a contravention on the previous inspection in November 2023.
      • 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 Licensee's system to ensure each person is weighed monthly was found to be ineffective. During the inspection, person in care charts were reviewed. In one chart it was noted that no weight had been recorded for five months. In two other charts it was noted that monthly weights were not being consistently documented, with various months missing throughout the last year.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The Licensee's system to ensure medications are securely stored was found to be ineffective. During the inspection, prescribed topical medications were found, unsecured, in person in care's rooms.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): During the inspection it was noted that a vitamin container did not have a label from the pharmacy. This was also noted on the medication safety and advisory committee (MSAC) minutes from December 2024.
      • R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
  3. Substantiated complaint

    2 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Allegation - The Licensee is in non-compliance with Residential Care Regulation (RCR) 61 as it pertains to employees touching their hair and not washing their hands prior to assisting persons in care with meals. Findings - Substantiated. During the investigation it was discovered that there is no system in place to ensure that hand hygiene audits are being conducted in the dining area. Hand hygiene audits are being routinely performed, but the forms do not specify where the audits are occurring.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • 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): Allegation - The Licensee is in non-compliance with RCR 81(2)(b) as it pertains to a person in care not being put to bed when they request. Findings - Substantiated. During the investigation, the person in care's care plan was reviewed and was noted to not have a bedtime preference. However, once this concern was brought to the attention of the manager, the care plan was revised to reflect this. Allegation - The Licensee is in non-compliance with RCR 82 as it pertains to persons in care not having access to and not being provided the appropriate incontinence products to ensure individual needs are being met. Findings - Unsubstantiated. During the investigation, it was discovered that employees were not following care plans regarding types and sizes of incontinent products. This resulted in the facility being temporarily short products for some persons in care. This issue had been self-identified by the Licensee and actions were taken to resolve this issue prior to this complaint investigation.
      • 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)
      • R10.3M - 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
  4. Routine Inspection

    5 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The Licensee's system to ensure that Medication Administration Records (MARs) are accurate was found to be ineffective. During the inspection, one MAR was found to be missing 12 initials, which indicate if a medication has been given or not, over a 16 day period.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 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 Licensee's system to ensure that refrigerator temperature checks are completed was found to be ineffective. During the inspection, on one monitoring sheet it was observed that 14/32 temperature checks were missing.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Licensee's system for ensuring the menu posted contains snacks with 2 food groups was found to be ineffective. During the inspection, menus in 2 dining rooms did not include snacks from 2 food groups. This was also noted as a contravention on the previous inspection.
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The Licensee's system to ensure that medications are safely and securely stored was found to be ineffective. During the inspection, a medication cart was noted to be unlocked and unattended in an area that persons in care are able to access it. A health and safety plan was requested, obtained and accepted by Licensing.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The Licensee's system to ensure that care plans meet the requirements of the legislation was found to be inefficient. During the inspection, it was noted that persons in care who smoke do not have a care plan which addresses smoking and how to guide care.
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
  5. Routine Inspection

    5 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The Licensee's system to ensure that Medication Administration Records (MARs) are accurate was found to be ineffective. During the inspection, one MAR was found to be missing 12 initials, which indicate if a medication has been given or not, over a 16 day period.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 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 Licensee's system to ensure that refrigerator temperature checks are completed was found to be ineffective. During the inspection, on one monitoring sheet it was observed that 14/32 temperature checks were missing.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Licensee's system for ensuring the menu posted contains snacks with 2 food groups was found to be ineffective. During the inspection, menus in 2 dining rooms did not include snacks from 2 food groups. This was also noted as a contravention on the previous inspection.
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The Licensee's system to ensure that medications are safely and securely stored was found to be ineffective. During the inspection, a medication cart was noted to be unlocked and unattended in an area that persons in care are able to access it. A health and safety plan was requested, obtained and accepted by Licensing.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The Licensee's system to ensure that care plans meet the requirements of the legislation was found to be inefficient. During the inspection, it was noted that persons in care who smoke do not have a care plan which addresses smoking and how to guide care.
      • 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)
  6. Substantiated complaint

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Investigation Findings- It was found during the investigation that Licensing was not immediately notified when there was suspected physical abuse of a person in care.
      • R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Investigation Findings- It was found during the investigation that the facility policy of reporting suspected physical abuse to Licensing was not followed. Allegations were also brought forward regarding RCR 85(2)(b) and the orientation of the Clinical Services Lead. These allegations were found to be unsubstantiated.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Allegation-Person in care was denied access to their bedroom Residential Care Regulation section 26(1). Investigation Findings- During the investigation it was found that a person in care is denied access to their room by way of a cart being placed in front of their bedroom door. The allegation was found to be substantiated.
      • R7.1T - Each bedroom must meet the needs of and provide for the health, safety and dignity of the occupant; 26 ( 1 )
  7. Substantiated complaint

    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): Allegation - The Licensee is in non-compliance with Residential Care Regulation 48(1)(a) as it pertains to the rate of pay not being clear at the time of admission. Investigation Findings - It was found during the inspection, that at the time the person in care was admitted to the facility all charges, fees or payments were not made clear to the person in care or the person's representative. This allegation was found to be substantiated.
      • R2.1A - Advise of all charges/fees/other payments for accommodation/other services offered prior to admission; 48( 1 )(a)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Allegation - The Licensee is in non-compliance with Residential Care Regulation 22(1)(c) as it pertains to dirty cups in the common area of the facility being left overnight. Investigation Findings - It was found during the investigation, that there is a cleaning checklist for the common area; however, the Licensee was unable to provide documentation to indicate that this cleaning was completed for the day of the complaint. This allegation was found to be substantiated.
      • 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): Allegation - The Licensee is in non-compliance with Residential Care Regulation 82 as it pertains to a person in care's oral care plan not guiding employees to provide the oral care they require Investigation Findings - It was found during the investigation, that an oral care plan was put into place upon admission; however, this oral care plan did not provide care directives for their dental appliance. This allegation was found 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
  8. Routine Inspection

    2 infractions

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Licensing Officer observed Medication Administration Records where the documentation of PRN medications was not following facility policies. Comment: Licensing Officer observed a Restraint Management Plan that did not list any alternatives either implemented/rejected. It appears that these alternatives were discussed and rejected but not properly documented. Licensing Officer was informed that there was sufficient plan already in place to remedy this.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Licensing Officer observed a menu with evening snacks that did not contain at least two food groups or were nutritious. Licensing Officer was informed there is a secondary menu that will be immediately posted and implemented. This contravention was corrected during the inspection. Licensing Officer observed a week long snack menu that contained the same evening snack with no variety.
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
      • R5.1E - Provide a variety of foods in consideration of each person in care's nutrition plan and needs; 62( 2 )(c)(i)
  9. Monitoring

    3 infractions

    • RB1.13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): Recreational assessments and care plans have been developed for at risk persons in care, however not all persons in care have had a recreational assessment and care plan developed that identifies their needs and goals.
      • RB1.13A - Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
    • 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): Not all persons in care have a person specific recreational care plan in place that addresses their social and emotional needs as well as cultural and spiritual preferences.
      • 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): UNRESOLVED A process has been developed for a recreation assessment and a person specific recreational care plan to be completed for all persons in care. The recreation co-ordinator has identified all high risk persons in care and has completed an assessment and recreational care plan for those individuals. The facility manager stated that a plan will be developed to ensure all persons in care have a recreation assessment, and person specific recreation care plan in place. The manager stated the plan will be submitted to Licensing.
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
  10. Monitoring

    5 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): January 11, 2017 - The facility's system to ensure compliance with keeping a medication record (MAR) of all medications administered is ineffective. LO reviewed the MARs in three of the four neighbourhoods. One person in care's MAR was missing employee initials for six evenings when bedtime medications were administered.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): January 11, 2017 - The facility's system for ensuring compliance with maintaining equipment and furniture for use by persons in care is maintained in a clean condition is ineffective. LO observed seven chairs soiled with food/ spilled liquids, and dark stains in the dining room of Cottage 1. LO observed the dining room table legs to have dried food and liquids on them in the dining room of Cottage 1. LO observed a lift in a person in care's room that was visibly soiled with dirt, hair and food. LO inquired with two employees the process for the cleaning of the lifts. The employees stated that the lifts were to be cleaned with cavi wipes by the employees after each use.
      • R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): January 11, 2017 - UNRESOLVED - From July 2015 - The facility has been without a DOC since September 2016. This has resulted in the Manager being unable to complete the performance appraisals. LO observed a printed schedule for the appraisals. Employees are aware once the new DOC is hired (this week) and orientated the performance appraisals will restart.
      • 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): January 11, 2017 - The facility's system to ensure compliance with all rooms and common areas being in a good state of repair is ineffective. LO observed water damage to the counter, back splash, and cupboards below the sink in the servery area in Cottage 1.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): January 11, 2017 - The facility does not have a process in place to ensure that all medications are packaged and recorded on the MAR by the pharmacist. Upon inspection of a medication cart LO observed an unlabelled bottle of Tums, and an unlabelled tube of A535. The medications were not recorded on the MAR, nor was there a written order by the medial practitioner for either prescription.
      • R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
      • R9.1E - Administer only medications prescribed or ordered by the medical or nurse practitioner; 70 ( 1 )
  11. Monitoring

    12 infractions

    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): June 08, 2016 - The Licensee does not have a process in place for ensuring compliance with the regulation of prominently displaying the manager's name. The manager's name is not currently posted in the facility.
      • Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
    • 13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): June 08, 2016 - The Licensee's system for monitoring the compliance with care plans reflecting the persons in care's care needs is ineffective. LO reviewed 10 persons in care's charts and found the care planning did not reflect the persons in care's current status. A person in care who remains in bed did not have an activity or recreational care plan that addressed their social/recreational needs.
      • 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): June 08, 2016 - The Licensee's system for monitoring the compliance with care plans reflecting the person's in care's needs is ineffective. LO reviewed 10 persons in care's charts and found the care planning did not reflect the persons in care's current status. A person in care who remains in bed did not have an activity or recreational care plan that addressed their social/recreational needs.
      • 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.
    • 24 - Are persons in care or their representatives participating in the development and implementation of care plans?
      • Observation(s): June 08, 2016 - The Licensee currently does not have a process in place for persons in care and their family's to have input in the development of their care plans if the family is not present during the annual care conference.
      • Ensure persons in care or their representatives are able to participate in the development and implementation of their care plan.
    • 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): June 08, 2016 - UNRESOLVED - The Licensee's process for ensuring employees follow facility policies is ineffective. LO and the RN were unable to locate a post falls assessment, vital signs or ongoing monitoring of the person in care following their fall. Therefore the employees did not follow the facility's falls policy. The facility submitted a compliance plan following the last inspection stating that 1:1 meetings occurred between the care manager the ACC's and all LPN's to review the falls policy. The facility had only 1 food audit completed in the last year. LO reviewed the the facility's policy on food and food service audits and the facility is not following their policy.
      • 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): June 08, 2016 - Following the last inspection the Licensee established a new process for ensuring compliance with regular employee performance reviews. A recent change in management has occurred. LO discussed the new schedule with the manager and the facility will submit the schedule to licensing as a part of their compliance plan.
      • 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): June 09, 2016 - The Licensee's process for ensuring compliance with data entry of monthly weights into persons in care's charts is ineffective. LO and the RN reviewed persons in care's electronic charts and monthly weights were not consistently recorded in all persons in care's charts.
      • 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): June 09, 2016 - The Licensee does not have a process in place to ensure compliance with monitoring of the food services and nutrition care. The Licensee is not following their policy on food and food service audits as LO was able to locate only 1 audit dated May 2016.
      • Retain the results of monitoring of food services and nutrition care; 87(c)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): June 08, 2016 - UNRESOLVED - The Licensee's has established a process for ensuring compliance with storage of personal hygiene products. However the process is not being monitored as unlabelled nail clippers were found in the tub room during the inspection. The RN disposed of them at the time of inspection.
      • 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): June 08, 2016 - UNRESOLVED - The Licensee has replaced the carpets in the downstairs neighbourhoods with linoleum, however carpet remains in the upstairs neighbourhoods. The Licensee does not currently have a process in place for the monitoring of compliance with the carpet in the common areas being kept in clean condition. Dried emesis was found on the carpet in the upstairs lounge area. The carpets throughout the upstairs neighbourhoods have multiple various sized stains in the common areas and hallways that require cleaning. UNRESOLVED - The facility is not following their process for the safe and secure storage of prescription creams. LO located 3 prescription creams not securely stored in 3 different persons in care's rooms.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Ensure all medications are safely and securely stored; 69( 3 )(a)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): June 08, 2016 - UNRESOLVED - The Licensee is not following the process that is in place to ensure compliance with the safe and secure storage of medications. LO located 3 prescription creams that were not securely stored in 3 different person in care's rooms. Ensure that all medications in the community care facility are safely and securely stored 69(3)(a)
    • 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): June 09, 2016 - UNRESOLVED - The Licensee's system for monitoring the compliance with care plans reflecting the persons in care's care needs is ineffective. The Licensee currently does not have a process in place for persons in care and their family's to have input in the development of their care plans if the family is not present during the annual care conference. LO reviewed 10 persons in care's charts and found the care planning did not reflect the persons in care's current status. A person in care who remains in bed did not have an activity or recreational care plan that addressed her social/recreational needs, A person in care who suffers from frequent UTI's did not have a care plan in place to guide employees in recognizing symptoms of a UTI. A person in care's my day stated person in care may have inappropriate behaviours. However the care plan did not guide the employees for behavioural intervention.
      • 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)
      • 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)
      • 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)
  12. Monitoring

    17 infractions

    • 3.2 Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): Dec 16, 2015 - The needs of a resident were not met and a wound continued to worsen from Oct 17, 2015 to present. Feb 01, 2016 - Employees did not meet the needs of the persons in care when they did not reassess a resident post antibiotic use for a UTI. -Persons in care needs were not met when employees failed to reassess and document for 24-48 hours following a fall.
      • There must be sufficient numbers of trained and experienced employees on duty at all times. Staffing patterns must meet the needs of persons in care and assist persons in care with activities of daily living, including eating, mobility, dressing, grooming and hygiene in a manner consistent with the health, safety and dignity of persons in care; 42( 1 )(a)(b) (Show More)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): Feb 01, 2016 - UNRESOLVED Restraint Care Plans contain a reassessment date however they do not contain the result of the reassessment. -The employees have been documenting the reassessments of the restraints in the nursing notes not the restraint care plan.
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): Dec 16, 2015 - A reportable incident was not reported to Licensing, the funding body, the resident's doctor, or family at time of incident. Jan 15, 2016 - The incident of alleged sexual abuse was not reported to licensing, the resident's contact person, the family doctor or the funder.
      • Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77( 2 )(a)
      • Immediately notify the medical or nurse practitioner responsible for the person in care involved in a reportable incident; 77( 2 )(b)
      • 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)
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Feb 01, 2016 - UNRESOLVED - Chairs in the dining rooms were found to be dirty/stained and require cleaning. -UNRESOLVED - Chairs and sofas located in both upstairs and downstairs neighbourhoods were found to be thread bare and heavily stained. Manager stated that new furniture was due to be arriving any day. - 4 resident's wheelchairs were noted to be visibly dirty in downstairs neighbourhoods. -Medi-maid lifts stored in hallways used by multiple residents were found to be visibly dirty.
      • Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • 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): Feb 02, 2016 - The facility does not have a family council in place
      • Ensure persons in care and family members are allowed the opportunity to establish and participate in an annual council.
      • Ensure that the council(s) or if no council(s), a group, has the opportunity to meet with the licensee.
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): Feb 02, 2016 - MARs were found on top of unattended med carts that are stored in the hallway.
      • Respect personal privacy and keep records and personal information confidential.
    • 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): Feb 15, 2016 - Recreation care plans found in resident's charts were found to be vague and not resident specific.
      • 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.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Feb 01, 2016- The facility is not monitoring the care and services it is providing to residents.
      • 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): Feb 01, 2016 - The employees are not following the facilities falls policy. In two of the resident's charts that were reviewed vital signs were not documented in the nursing notes post fall. -Unable to locate documented post fall assessments or documentation for the monitoring of the resident for the 24- 48 hour period post fall. -Employees did not follow the facilities' complaint/dispute resolution policy when a concern was brought forward regarding an employee and a resident. -Employees did not follow the facilities' policy for reportable incidents when a concern was brought forward regarding an employee and a resident.
      • 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): Dec 16, 2015 - An RN in charge of managing a resident's wound had large gaps in follow up, assessments, and communication. Jan 15, 2016 - The employee covering for the manager at the time of an incident did not follow the facilities' policies, important information was not documented in the resident's chart, nor was the resident's contact person informed of the alleged incident. Feb 01, 2016 - LO reviewed documentation by an LPN that the RN would assess a resident. LO Unable to find any documentation from RN to show assessment and follow up had been completed by the RN. -LO reviewed documentation from HCA in regards to changes in resident's conditions. LO unable to locate assessments or documented follow up by an LPN or RN. Feb 01, 2016 -UNRESOLVED - Employee files are missing recent performance appraisals. Feb 01, 2016 - The fire drills are conducted around the same date of the month every month, and the same time of the day. LO unable to locate documentation of how the drill went, the amount of time it took to respond and clear area, what requires improvement, what went well.
      • 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)
      • 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)
      • Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Feb 01, 2016 -Nutrition care plans do not contain resident's current weight at time of dietician review.
      • 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): July 14, 2015 -UNRESOLVED - The facility is not keeping a record of the complaints/concerns brought forward and the responses to them. Jan 15, 2016- Unable to locate any documentation of the concern brought forward of alleged sexual abuse of a female resident by an employee. Unable to locate documentation of the response to the concern brought forward. Feb 01, 2016- UNRESOLVED - The facility does not have a family council in place.
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
      • Retain records of compliance with family and resident council required in section 59; 89( 2 )(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Feb 01, 2016 - An unlabelled razor and comb were found in the tub room. -The tub rooms have bins labelled with room numbers however the bins were empty. -Resident's toothbrushes and tooth paste are stored in a plastic container in their washrooms. LO noted in 10 resident washrooms hair brushes with hair in them to be stored in same container and often on top of their tooth brushes.
      • 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): Feb 01, 2016 - UNRESOLVED- Evidence of cigarette buts and ashes were found on a patio outside that is at times used by residents. -UNRESOLVED-Four week menu was not posted in two of the four dining rooms and the two menus that were posted were on different weeks. -Medication carts are stored unattended in the hallway outside of medication times. -MARs were found on top of the med carts that were stored unattended in the hallway. Thus leaving confidential information accessible to various individuals. -Walls were found to be heavily damaged in kitchen areas in downstairs neighbourhood and require repair and paint. -The lower walls in hallways are damaged and require repair. -Walls in a lounge/TV area were heavily damaged. -An area rug was found at the entrance of a resident's room in a downstairs neighbourhood, creating a tripping hazard. -A housekeeping cart was located unattended in the hallway - the cubby door to where chemicals are stored was locked, however LO gently pulled on door and it easily opened.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Ensure that no one other than a person in care smokes while on the premises; 23(a)
      • 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 ( 4 )
      • Ensure all medications are safely and securely stored; 69( 3 )(a)
    • 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): Feb 01, 2016 -LO unable to find documented evidence in nursing notes of resident's heath and safety being promoted. -LO unable to locate documentation of assessments and monitoring by LPNs and RNs for residents who had wounds that were not improving, had multiple falls, and had completed a course of antibiotics for a UTI. - - ,
      • Promote the health, safety and dignity of persons in care; CCALA 7( 1 )(b)(i)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Feb 01, 2016 - Resident's nursing notes were reviewed and found to be missing ongoing monitoring and assessments by LPN's and RN's when a change in condition was noted and documented by HCAs. -LO reviewed documentation of a resident who is a high falls risk and is required to have hip protectors(HP) on 24/7 - it was documented almost nightly that the resident did not have the HP on at night due to being soiled. There was no documentation of problem solving to ensure resident wore hip protectors 24/7. -LO unable to locate purple dots on Resident's doors, plan of care in rooms, walkers or wheel chairs to indicate to others there is potential for aggression. -Unable to locate reassessments of purple dot for residents to indicate that it is still required. -LO unable to locate up to date Braden scales, pain assessments, and Scott falls assessments for residents who required them. UNRESOLVED - There is no family council currently in place.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • Provide at least an annual opportunity for persons in care and their parents or representatives, family members and contact persons to establish councils or similar organizations to represent the interests of persons in care; 59(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): Feb 01, 2016 - Nursing notes and care plans were reviewed. LO noted that residents' behaviours of barricading bedroom doors was not addressed in their care plan. -Oral Care plans are missing resident specific information for the type of assistance required, missing was resident's type of teeth-ie-dentures, partial, natural teeth. -Nutrition care plans do not have a date that they were last reviewed by the dietician. -Falls care plans were found to be missing some of the fall precautions in place- ie - Falls mat and bed alarm noted in room however was not on falls care plan. -Recreation care plans were noted to be vague and not resident specific listing goals, activities enjoyed -Care plans were not updated for residents who had changes in condition. -A resident's care plan for bladder management stated they had a catheter however there was no date of original insertion date, date it was last changed, the date it is required to be changed, or the size of catheter. -A resident who had open wounds did not have a care plan in place for the management of the wounds. -Care plans are not updated for residents who experience a change in their mobility.
      • 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)
      • 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)
      • 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)
      • 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)
      • 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)
  13. Monitoring

    13 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): July 14, 2015 - UNRESOLVED - from an inspection in April 2015. The policy is currently being reviewed and updated at the corporate level.
      • 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).
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): July 14, 2015 - Restraint Care Plans contain a reassessment date however they do not contain the result of the reassessment. - The alternatives that were considered are not documented on the restraint Care Plan.
      • 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 result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 5 )
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): July 14, 2015 -All of the furniture in the lounge areas of the downstairs neighbourhoods was found to be dirty and stained. - Many pieces of furniture appear to be thread bare. - Chairs located in the dining rooms of the downstairs neighbourhoods are stained. The legs and arms of chairs are dirty. - There is a chair located in a upstairs lounge area that has a sharp wire protruding form the seat area of the chair.
      • 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)
      • Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): July 14, 2015 - The restraint care plans do not include information of how often the restraints are to be released and what care is to be given at this time.
      • Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
    • 10 -Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): July 14, 2015 - A number of staff files were reviewed and were found to be missing, reference checks, work history, copies of diplomas for Care aids and nurses as well as evidence of current registration for nursing staff, TB screens, immunization screens, current First Aid Certificates, food safe and recent performance appraisals.
      • 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 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)
    • 4.6 Are facility records current and complete?
      • Observation(s): July 14, 2015 - The facility is not keeping a record of the complaints/concerns brought forward and the responses to them. - There was one chart that was located in an unsecure area in a downstairs neighbourhood. - RESOLVED - during inspection.
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 5 )
      • Ensure records related to a person in care are accessible only to employees who require access to perform their duties in relation to the person; 91 ( 7 )
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): July 14, 2015 - The 4 week menu did not contain 2 nutritious snacks daily form 2 separate food groups.
      • 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): July 14, 2015 - There are refrigerators in the kitchen areas of the downstairs neighbourhoods. The thermometers were reading 7 degrees Celsius on the day of inspection. The monitoring sheets show the temperatures ranging from 5-11 degrees Celsius with no corrections taken.
      • 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): July 14, 2015 - All of the carpets in the downstairs neighbourhoods are dirty and heavily stained. - Carpets in upstairs halls and common areas have stains. - Door knobs, walls, and hand rails are dirty in the downstairs neighbourhoods. - Upstairs patio decks have a large amount of bird feces from the birds nests that are located above in the overhang. - Cigarette ashes were located in the court yard of a downstairs neighbourhood. - Evidence of staff smoking on a patio outside that is used by residents at times. - Alcohol was found stored in a Resident's personal fridge in his room -RESOLVED- during inspection. - The fridge, cupboards and drawers in cottage 1 kitchen were found to be dirty. - Resident's bathrooms contain a shower with a large piece of rubber (stopper) surrounding the bottom of the shower. This is to separate the shower floor from the reaming bathroom floor. This appears to be a tripping hazard for Residents. One of these rubber stoppers was torn and there was water found on resident's bathroom floor. - There were nursing and storage areas that were found unlocked. Staff purses and bags are stored in these areas and accessible to Residents. -The weekly menu was not displayed in any of the 4 dining rooms.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Ensure that no one other than a person in care smokes while on the premises; 23(a)
      • 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 )
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): July 14, 2015 - A package of Rolaids and bottle of Tums was located in a Resident's room. There is no medication self administration care plan in place nor was the medication stored in a secured location.
      • Permit self-administration of medication when a plan is approved by the medication safety and advisory committee and medical or nurse practitioner, and is included in the person's care plan; 70( 4 )(a)(b)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): July 14, 2015 - A Resident's Chart was reviewed and it was discovered that there was a significant time lapse of communication between nursing staff and the doctor for a Resident who was experiencing significant changes in their medical condition. - All Residents do not carry facility ID on them when they temporarily leave the facility. -The facility has not had a family or council meeting for quiet sometime. They have one scheduled to occur with in the next month.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 5 )
      • 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 )
      • 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)