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Good Samaritan Canada Village by the Station

270 Hastings Ave Penticton BC V2A 2V6 · Residential Care - Licensing

13 inspections

  1. 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): Current employee file observed to have an expired Criminal Record Check; per site policy all employee Criminal Record Checks are to be renewed every 5 years. Immediate Health and Safety Plan requested, submission of plan received and accepted. Failure to monitor validity of employee Criminal Record Checks can pose risk to the health and safety of persons in care. Several Medication Administration Records reviewed; in which PRN(as needed) medication effectiveness is not documented. If staff are not able verify whether the PRN medication was effective or not, this can lead to compromised safety and wellbeing of persons in care. 1 chart reviewed that has a restraint agreement, however restraint monitoring documentation is incomplete/missing for several dates. Incomplete restraint monitoring documentation can result in unsafe practices and possible injury posing serious risk to persons in care. Please submit a corrective action plan by December 29, 2025, advising how all current and future restraint monitoring /medication administration documentation will be completed in an accurate, timely and efficient manner.
      • 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): Dining area sinks accessible to persons in care water tested to be above 49° Celsius. Maintaining water temperature below 49° Celsius is a critical safety measure to protect persons in care from preventable harm including risk of burns. Please submit a corrective action plan by December 29, 2025, advising how current and future water temperatures accessible to persons in care will be maintained and monitored to ensure not heated above 49° Celsius.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
  2. Routine Inspection Follow-up

    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): The system to ensure that policies and procedures are reviewed and, if necessary, revised at least once each year is ineffective. Two out of three policies and procedures produced by the Licensee were last reviewed in October 2023. *This is a repeated contravention. The system to ensure that policies are implemented by employees is ineffective. The facility policy and procedure entitled Safe Resident Handling and Mobility was not followed as the person in care was transferred to bed by one staff member using a mechanical lift, when two staff members are required.
      • 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 system to ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan is ineffective. A staff member reported they did not follow the mobility terms as set out in one person in care's care plan, when two person assist was required.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  3. Substantiated complaint

    1 infraction

    • 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 60(a). Investigation Findings - Licensing reviewed progress notes, care conference notes, information from the complainant, and correspondence from the Licensee. After review and based on the balance of probability, the allegation of non-compliance is unsubstantiated. Allegation - The licensee is in non-compliance with Residential Care Regulation 85(1)(d). Investigation Findings - Licensing reviewed information from the complainant, and correspondence from the Licensee. Licensing conducted two site visits observing a door was open, contrary to facility policy. Staff not following policies could increase the risk for persons in care, specifically potential elopement. Licensing is requesting a plan to ensure staff follow the current policy/procedure. The allegation is substantiated.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  4. Routine Inspection

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing Officer was notified of previous structural work at the facility where a plan was not submitted to Licensing.
      • R1.1B - Submit plans for the change to licensing and receive written approval prior to making any structural changes; 8( 2 )(a)(i)
    • 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 reviewed Medication Administration Records showing instances where staff were not charting as per the policies. Licensing Officer reviewed two restraint monitoring records, both of which contained instances where staff were not charting as per the policies.
      • 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): Licensing Officer did not observe the weekly menu in a prominent place as required by the Regulation.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
    • 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): Licensing Officer observed a care plan for restraints which also contained outdated information, therefore not ensuring the care is consistent with the care plan. Licensing Officer received a corrective action plan during the inspection which was accepted and implemented. The contravention was corrected during the inspection.
      • 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
  5. Routine Inspection

    5 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): Licensing Officer observed a restraint monitoring sheet that was inefficient in ensuring compliance with the Regulation and the facility policies.
      • 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): Fire emergency plans were not kept in a prominent place. The plans were printed and placed in the emergency binder, therefore this was corrected during the inspection. Licensing Officer observed a housekeeping closet and nursing station door that were open and accessible, this was contrary to facility policy. Licensing Officer observed a staff file that was missing evidence of first aid certification, this was contrary to facility policy.
      • R2.1I - Display a copy of the emergency plan in a prominent place; 51 ( 4 )
      • 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 the menu that did not contain two snacks as required. This was corrected during the 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing Officer observed a refrigerator which contained items for persons in care but the temperature was not being monitored.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing Officer observed a section of the facility where the menu was not displayed in a prominent place. This was corrected during the inspection.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
  6. Routine Inspection

    3 infractions

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Licensing Officer observed a hydration tracking form that was not being completed by staff as per policy. Licensing Officer discovered a door to a nursing station and another door to a housekeeping closet containing cleaning chemicals which were both unlocked; this was contrary to facility policy. The contravention was corrected during the inspection. Licensing Officer observed charting for pro re nata (PRN)medications which were not done as per facility policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): Licensing Officer observed three staff files. One of those three staff files did not contain character references. Two of those three staff files did not contain records of employee compliance with the Province's immunization and tuberculosis control programs.
      • R4.4B - Keep employee character references; 86(b)
      • R4.4C - Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
    • R4.6 - Are facility records current and complete?
      • Observation(s): Licensing Officer observed 3 staff files that contained outdated policy agreements.
      • R4.6L - Ensure all records are current; 91( 1 )(a)
  7. Routine Inspection

    0 infractions

  8. Monitoring

    0 infractions

  9. Monitoring

    2 infractions

    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): June 26, 2017 - UNRESOLVED - The facility's system for ensuring compliance with maintaining the persons in care's personal health and hygiene is ineffective. LO observed a used unlabelled metal nail file stored in the cupboard in a tub room.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): June 26, 2017 - The facility's system for the monitoring of the persons in care to ensure their needs continue to be met is ineffective. LO observed a person in care's MAR and it was indicated that a treatment ointment was to be applied as needed for 7 days. The Mar was set up to apply the ointment three times a day for 7 days as per the doctor's order. The MAR was initialled three times during the 7 days. It was recorded in the MAR after each application that the ointment was not effective, and leg looked the same. In the person in care's nursing notes it was documented that the ointment was ordered for 7 days. On the 6th day the documentation in the nursing notes stated that the leg was assessed and it continues to be red, edematous, and warm to the touch and that the prescription is finished the next day. There is no further documentation to indicate that the doctor was made aware that the ointment was only used 3 times over a 7 day period, and the leg remains swollen, red, and warm to the touch. There is no further documentation to indicate what condition the person in care's leg is in at the present.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  10. Monitoring

    11 infractions

    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): October 21, 2016 - The facility's system for ensuring compliance with documenting in the restraint care plan of alternatives that were considered or trialed prior to the use of the restraint is ineffective. LO inspected three person in care's restraint care plans. The alternatives that were considered or trialed were not documented on the restraint care plan. October 21, 2016 - The facility does not have a system in place for ensuring compliance with the documentation of the results of restraint reassessment. LO observed three persons in care's restraint care plans and observed that there was a date and a signature indicating that the restraint was reassessed however there is no documented result of the reassessment.
      • 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)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): October 21, 2016 - The facility's system for ensuring compliance with documenting in the restraint care plan of alternatives that were considered or trialed prior to the use of the restraint is ineffective. LO inspected three person in care's restraint care plans. The alternatives that were considered or trialed were not documented on the restraint care plan.
      • Ensure all alternatives to the use of a restraint have been considered and either implemented or rejected; 73( 2 )(a)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): October 26, 2016 - The facility does not have a system in place for monitoring the services they provide to the persons in care. This has resulted in the infractions listed within this report.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 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): October 26, 2016 - The facility does not have a system in place to ensure compliance with creating, updating, and monitoring of care plans for persons in care to reflect their current behaviours, recreational needs, and status changes.
      • 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.
    • 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): October 21, 2016 - The facility's system for ensuring compliance with employees following the facility's policies and procedures is ineffective. LO inspected a person in care's chart and found that they had several falls within the last month. There was no assessment or follow up documented in the nursing progress notes or on the neuro vital sheets following the fall as indicated in the facility's fall 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): October 26, 2016 - The facility does not have a system in place to ensure compliance with a supervision of the preparation and delivery of food by an individual who is a member of CSNM. The facility is currently not monitoring or supervising the preparation and delivery of food. LO inquired what system the facility had in place to ensure they were in compliance with the Residential Care Regulations and as they did not have one other than the cooks take food temperatures.
      • The food services manager must be either a nutrition manager with membership in the Canadian Society of Nutrition Management (CSNM), a person eligible for membership with the CSNM, or a dietician (Applies to 50 or more persons in care); 44( 2 )(a)(b)(c)
    • 4.6 Are facility records current and complete?
      • Observation(s): October 21, 2016 - The facility does not have a system in place for ensuring compliance with the monitoring and recording of food services and nutrition care. The facility is not monitoring the food services and nutrition care that is being provided to the persons in care.
      • 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): October 26, 2016 - The facility's system for ensuring compliance with maintaining person in care's personal health and hygiene is ineffective. LO observed ten persons in care's personal hygiene products all stored together and not all items were clearly labelled. LO observed an unlabelled disposable razor stored in a bin with other razors that had rust and hairs wedged in the blade. The facility does not have a system in place for monitoring compliance with safe storage of food in person in care's personal fridges. LO observed a personal fridge in a person in care's room that contained dairy products and deli meats. The monitoring sheet on the fridge was being completed by the person in care however it did not indicate the fridge had the safe temperatures of 0-4 degrees Celsius. There was no evidence of monitoring or follow up by the facility to ensure the food was safely stored. The temperature monitoring sheets located on the fridges in the neighbourhoods contained various recorded temperatures. Temperatures were often recorded above 4 degrees Celsius however there is no documentation showing corrective measures were taken. LO has referred the facility to their Environmental Health Officer to review their food safety plan.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): October 26, 2016 - The facility's system for ensuring compliance with the safe storage of hazardous products is ineffective. LO located cleaning cavi wipes (hazardous to skin) in a person in care's bathroom and in a hallway beside the stationary bike, therefore leaving hazardous products accessible to persons in care.
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): October 26, 2016 - The facility's system for monitoring persons in care to ensure their needs are met is ineffective. LO inspected a chart of a person in care who had increased behavioural challenges and aggression over a period of a month. The nursing staff had faxed the doctor who ordered an antibiotic for query of a urinary tract infection. There was no documentation in the progress notes to indicate the person in care was monitored or assessed while taking the antibiotic or once the course of the treatment was completed.
    • 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): October 26, 2016 - The facility does not have a system in place to ensure compliance with creating, updating, and monitoring of care plans for persons in care to reflect their current behaviours, recreational needs, and status changes. LO inspected two persons in care's care plans who were identified by a purple dot to have aggressive behaviours, however the care plans did not identify what the behaviours were nor did they offer ideas or techniques to help guide the staff in providing care and interacting with the person in care to help promote their health safety and dignity. LO observed a care guide posted in a person in care's room that had a purple dot indicating aggressive behaviours. However there was no care planning for aggression. When LO discussed this with the care manager she stated the person in care was no longer requiring a purple dot to indicate aggression. LO and care manager were unable to locate the reassessment documentation supporting the removal of the purple dot, as indicated in the facility's procedure for purple dots. LO observed a care guide posted in a person in care's room to have a purple dot. However there was no purple dot on the person in care's picture out side of their room to indicate a warning of potential aggression as indicated in the facility's procedure for purple dots. LO inspected a recreation care plan that was not updated to reflect resident's current status. LO spoke to the activity co-ordinator and it was identified that there is no system in place for activities to ensure that a person in care's recreation care plan is updated upon a status change. Currently they are updated quarterly.
      • 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)
      • 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
  11. Monitoring

    13 infractions

    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): March 29, 2016 - The facility's system for ensuring compliance of documented reassessment of restraints in restraint care plans is ineffective. Resident's restraint care plans reviewed did not consistently contain reassessment documentation.
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): March 29, 2016 - The facility's system for documentation of the resident's influenza immunization status is ineffective. It is not documented as a clear and up to date record. The influenza immunization is documented on the MAR in the month the immunization is received, refusal is documented in the nursing notes, thus the records cannot readily be accessed.
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): March 29, 2016 - The facility's system for ensuring compliance of documented reassessment of restraints in restraint care plans is ineffective. Resident's restraint care plans reviewed did not consistently contain reassessment documentation.
      • Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): March 23, 2016 -The facility's system to ensure compliance with the physical environment and the care and services provided to residents is ineffective. This has resulted in the infractions noted in the report below. -The manager's name is not displayed in a prominent location 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)
      • Regularly monitor the physical environment and the care and services provided; 61
    • 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): March 30, 2016 - The facilities process for monitoring the health and safety of each resident has broken down. LO reviewed a resident's chart to find an antibiotic had not been reassessed upon completion, and the nursing assessments documented indicated infection was still present. No further action had taken place.
      • Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • 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): March 30, 2016 -The facilities process for monitoring resident's care plans to ensure they are up to date and reflect resident's current status has broken down. LO reviewed a resident's care plan and it did not reflect her current status and care 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.
    • 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): March 23, 2016 - Please refer to The Pharmacy Operations and Drug Scheduling Act. As a medication cart was observed to be locked and stored unattended in the resident's hallway. The medication cart was moved to the locked medication room during inspection.
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): March 23, 2016 - The facility's system to ensure compliance with the TB Control Program is ineffective. Two new employee files reviewed were missing TB screens.
      • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): March 29, 2016 - The facility's system to ensure compliance with documentation of resident's monthly weights in their charts is ineffective. Resident's electronic charts reviewed were missing consistent documentation of monthly weights.
      • 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): March 23, 2016 - The facility's system for ensuring compliance with the documentation of complaints and concerns is ineffective. It was identified during the inspection that RNs and LPNs have not been documenting the concerns brought forward and their responses to them.
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s):
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): March 29, 2016 - The facility system for monitoring residents to ensure their needs are met is ineffective. LO reviewed a resident's chart to find an antibiotic had not been reassessed upon completion, and the nursing assessments documented indicated infection was still present. No further action had taken place.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
    • 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): March 29, 2016 -UNRESOLVED - The facility system for monitoring resident's care plans to ensure they reflect their current status is ineffective. A care plan reviewed did not reflect a resident's current status and care needs.
      • 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

    20 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): February 03, 2015 - UNRESOLVED - The falls policy is being revised at the corporate level and has not been released.
      • 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).
    • 3.2 Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): February 03, 2015, and April 10, 2015 - UNRESOLVED - The facility continues to work short staffed on a regular basis and the resident's care needs are not being met.
      • 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)
    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): August 17, 2015 - MARs are missing staff initials for routine medications administered. August 17, 2015 - The effectiveness of PRN's administered is not documented.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): April 10, 2015 - UNRESOLVED - The facility continues to not submit incident reports to licensing for some reportable incidents.
      • 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)
      • Retain a record of reportable incidents involving persons in care; 88(c)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): August 17, 2015 - Unable to locate TB screens in newly hired staff's files.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): April 10, 2015 - UNRESOLVED - The phone and call bell system is currently being replaced and the facility has a heath and safety plan in place until the instillation is complete.
      • Ensure controls for signalling devices, lights and elevators are accessible and easy to use; 14 ( 3 )
      • Provide a monitoring system or signalling device that is appropriate to the needs of persons in care; 19( 1 )(a)
      • Provide a monitoring system or signalling device that will identify the location of the person in care; 19( 1 )(b)
      • Provide a monitoring system or signalling device that will signal that a person in care needs immediate assistance; 19( 1 )(c)
      • Provide communication devices and other means of communication that enable employees to communicate with each other in respect of the needs of persons in care; 19( 2 )(c)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): August 17, 2015 - The reassessment of the resident's restraints is not being documented on their restraint care plan. The Care manager is documenting restraint reassessments for all residents on one sheet that it is located in the manager's office.
      • Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
    • 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • 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?
      • 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?
      • 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): August 21, 2015 - The facility did not respond in a timely manner to a complaint that was brought forward by a family member re verbal/emotional abuse in May 2015. April 10, 2015 - UNRESOLVED - The facility's orientation package, and the policy and procedure for orientation does not include orientation to the Residential Care Regulations and the Community Care and Assisted Living Act. April 10, 2015 - UNRESOLVED - The staff continue to not follow the facilities policy for reportable incidents.
      • Respond to all complaints, concerns, disputes promptly. 60(c)
      • Ensure policies are implemented by employees; 85( 1 )(d)
      • Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): February 03, 2015 - UNRESOLVED - Unable to locate TB screens for two newly hired employees. August 17, 2015 - Unable to locate first aid certificates for newly hired LPN's.
      • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
      • Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): August 17, 2015 - The MAR's are stored on the top of the medication carts in the hallways, leaving resident's personal information accessible to anyone.
      • Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • 4.6 Are facility records current and complete?
      • Observation(s): August 17, 2015 - The complaints that have been brought forward do not include management's responses to them. August 17, 2015 - The facility does not retain records of compliance for the supplements that are administered to the residents.
      • 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 individual nutrition needs required in section 66; 89( 2 )(c)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): August 17, 2015 - Resident's personal refrigerators are not monitored daily for temperatures or expired food. A resident's fridge was above the safe range of 0-4 degrees Celsius. It had been documented several times as being out of range without any actions taken to adjust the temperature.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): February 03, 2015 - UNRESOLVED - The hallway carpets remain heavily stained. April 10, 2015 - UNRESOLVED - The facility is currently in the process of replacing the entire phone and call bell system. August 17, 2015 - The laundry room was found propped open with hazardous materials accessible to residents. The manager closed the door however it was unable to be locked at the time.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
      • Ensure that laundry facilities if not used by persons in care, cannot be accessed by persons in care; 35( 2 )(b)
    • 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): April 10, 2015 - UNRESOLVED - The facility continues to work short staffed. Resident's health, safety and dignity is not being promoted. August 17, 2015 - The facility does not have locking doors at the main entrance. Therefore they do not monitor the individuals who enter and leave the facility including residents.
      • 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): April 10, 2015 - August 21, 2015 - UNRESOLVED - The facility is not providing ongoing monitoring to the residents to ensure their care needs are met.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
    • 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): August 17, 2015 and August 21, 2015 - Residents care plans do not reflect all of their care needs or ongoing medical concerns, nor are families consulted when developing the care plans. August 17, 2015 and August 21, 2015 - LO reviewed resident's nursing notes and care plan. The changes made to the resident's nutritional supplements by the dietician was not documented in the care plan.
      • 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)
      • 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)
  13. Monitoring

    13 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Feb 03, 2015 - The falls prevention policy does not detail post fall follow up. The reason for follow up assessments and documentation is to rule out any injuries that may arise in following hours or days post fall.
      • Written falls prevention policies and procedures are required for assessing risks that may result in a person in care falling including a plan for preventing falls, responding to falls suffered and including care and subsequent prevention(Applies only to Long Term Care); 85(2)(a)(i)(ii)(iii).
    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): UNRESOLVED from 2012 - MARs continue to have a significant amount of missing initials for routine medications. Also MARs are missing documented effectiveness of PRNs administered.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78(2)(b)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): Feb 03, 2015 - There is no documentation of safety checks when residents' are in restraints.
      • Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
    • 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 (1)
    • 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): There is a fridge in one cottage that is visible to residents and families that has a broken handle and is taped on to fridge.
    • 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 03, 2015 - The policy for restraints does not reflect the requirements of the RCR. - The staff are not following their policy by documenting safety checks of Residents in restraints. It is listed on their daily to do sheet however it is not documented.
      • Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85(1)(a)
      • 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): Feb 03, 2015 - Some staff files were found to missing TB and immunization screens as well as character references. UNRESOLVED from July 23, 2014 - Performance evaluations for staff have not been conducted in several years.
      • Obtain character references for all employed persons; 37(1)(b)
      • 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)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): UNRESOLVED from July 23, 2014 - Electronic charts were reviewed and monthly weights were found to be missing in some charts.
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83(4)(a)(c)
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Keep employee character references; 86(b)
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 4.6 Are facility records current and complete?
      • Observation(s): Feb 03, 2015 - The facility responds to complaints brought forward however there is no documentation describing the responses to the complaints.
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 (1)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): UNRESOLVED from July 23, 2014 - Found in the tub room were unlabelled nail clippers, nail files, combs and brushes. Feb 03, 2015 - Residents have personal fridges in their rooms that are not monitored for temperature or expired food. Food found not dated in fridges. Fridges in the upstairs neighbourhoods read above 4 degrees Celsius. Reference range is 0-4 degrees. Monitoring sheet stated 4 degrees every day it was recorded.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 (1)
      • Ensure that food is safely prepared, stored, served and handled; 63 (1)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Feb 03, 2015 - There continues to be lower wall, baseboard, and door frame damage to both Resident's rooms and hallways. There were many stains noted to the carpet in hallways. -A resident who self administers medication does not keep it in a safe and secured area.
      • 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 a safe and secure storage area for self-administered medications; 69(3)(b)(i)
      • Ensure that persons in care who self-administer medications store all medications in the safe and secure storage area provided; 69(3)(b)(ii)
    • 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 03, 2015 - In the complex care building resident's behaviour care plans are not detailed and specific. The purple dot assessments are not up to date in this area. -Oral care plans are inadequate as they do not contain detailed resident specific information. -Some recreation care plans are detailed and specific, however the majority of them do not contain resident specific information on them. Ie, interests or information of things that bring them joy. -Some care plans were found to have information on them that did not pertain to the resident, -The care plans are not being monitored for accuracy and implementation.
      • Care plans must include a plan to address behavioural intervention, if applicable; 81(3)(a)(ii)
      • Care plans must includes an oral health care plan; 81(3)(b)
      • Care plans must include a recreation and leisure plan; 81(3)(d)
      • Each care plan must be monitored on a regular basis to ensure proper implementation; 81(4)(a)