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Haven Hill Retirement Centre

415 Haven Hill Rd Penticton BC V2A 4E9 · Residential Care - Licensing

10 inspections

  1. Routine Inspection

    3 infractions

    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Bistro room refrigerator and medication room refrigerator observed to have un-labelled food items. Un-labelled food items pose risk to persons in care as it cannot be safely monitored for contamination. Please submit a corrective action plan by October 24, 2025, advising how all food items accessible to persons in care will be stored in safe and secure manner.
      • 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): -Courtyard area contained heaving in cement walkway -TV on wall in dining room area contained several hanging cords Physical maintenance concerns that contain tripping hazards and entanglement risk can pose risk of harm to the health and safety of persons in care including risk of falls, and injury. Please submit a corrective action plan by October 24, 2025 to advise how all common areas will be corrected and maintained in a safe condition. -Three resident room bathroom sinks water tested to be above 49° Celsius. -Family dining room area accessible to persons in care observed to have a coffee maker with spigot that dispenses boiling hot water (confirmed hot water exceeds 49 degrees). 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 October 24, 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. Several persons in care bathrooms observed to have unsecured topical medicated ointments. Unsecured medications can pose risk of harm as persons in care may access and ingest medications incorrectly or medications not prescribed to them. Please submit a corrective action plan by Oct 24, 2025, advising how all medications will be stored in a safe and secure manner.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • 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)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): It was determined a care plan for a person in care that contained specific directions for smoking supervision was was not being followed. Not following care plan requirements can lead to unsafe care that does not reflect the persons in care needs. Please submit a corrective action plan by October 24, 2025, advising how current and future care plans will be followed in a safe and effective manner.
      • 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
  2. Routine Inspection

    4 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Licensing Officer observed a restraint agreement which did not contain a reassessment date.
      • R10.4N - 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)
    • 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 restraint monitoring documentation. There was one day where staff was monitoring every two hours instead of every hour as per the restraint agreement.
      • 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 where the breakfasts did not contain three food groups. Licensing Officer observed the menu which did not list any snacks.
      • R5.1C - Provide for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups described in Canada's Food Guide; 62( 2 )(a)
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Licensing Officer observed that there was no system to ensure persons in care had identification as per the Regulation. This was corrected during the inspection.
      • R10.2L - Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56( 1 ) ( 2 )
  3. Routine Inspection

    4 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Licensing Officer observed three persons in care's charts which all did not contain completed immunization screening.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • 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 two staff files which both had incomplete orientation checklists contrary to facility policy. Licensing Officer observed a person in care's chart which contained a resident data form and an admission checklist form, both of which were incomplete which is contrary to facility policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Licensing Officer observed a staff file which did not contain copies of diplomas, certificates, or other evidence of training and skills. This was corrected during the inspection.
      • R3.1E - Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37( 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): Licensing Officer observed a care plan that was not updated after a substantial change in the circumstances of the person in care.
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  4. Routine Inspection

    6 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Contravention: Licensing Officer observed one restraint agreement that was missing the person in care/representative signature. This was corrected during the inspection.
      • R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Contravention: Licensing Officer observed two brooms that were in areas accessible by persons in care. Licensing Officer was informed that the facility will be posting their most recent inspection report in two separate places rather than one, to ensure that it's displayed in prominent places for all to see.
      • 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): Contravention: Licensing Officer observed a "family binder" that had a care aid job description from 2013, this was against facility policy. This was corrected during the inspection. Contravention: Licensing Officer observed three care plans that did not have the required immunization screening completed, contrary to facility policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Contravention: Licensing Officer observed that about half of the employee performance reviews were last completed in 2018 and the other half in early 2020.
      • 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)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Contravention: Licensing Officer observed the 4 week menu which did not have the AM snack listed, nor did the HS snack listed on the menu have at least 2 food groups.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Contravention: Licensing Officer observed an instance where a person in care who temporarily left the facility did not have written documentation in his possession as required. Licensing Officer was informed that a family and resident council meeting is overdue due to COVID-19; the most recent being March 6, 2020. A meeting is being planned for early September, 2021.
      • R10.2L - Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56( 1 ) ( 2 )
  5. Routine Inspection

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): A reportable incident from September 2019 was not submitted to Licensing Direct. Reviewed that recent Incident Report forms have been incomplete. Education and information has been provided. A second compliance plan has been requested to ensure that these forms are immediately submitted and do not require follow up by licensing to obtain sufficient information.
      • 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)
    • RB1.10 - Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
      • Observation(s): See question R10.2 that has been noted on this report.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The effectiveness of PRN’s are not consistently recorded or viewed prior to administering repeat PRN's.
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Prescription medication cream was accessible in an unlocked cabinet in a washroom.
      • 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): The last family and resident council or similar organization is reported to have occurred in February 2018.
      • R10.2R - 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)
  6. Routine Inspection

    8 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system in place to ensure that Care Aides are signing and documenting the treatments that are applied to persons in care is ineffective. The site now has a computerized electronic medication system in place, however the treatment administration records are signed on paper by Care Aides, and theses were found to be missing signatures and documentation.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): The system in place to ensure that the furniture used by persons in care is in a good state of repair is ineffective. During the physical inspection of the building LO noted a leather couch located in a locked unit to have a large rip in it, and a leather chair to be heavily cracked, thus leaving the surfaces of both pieces of furniture porous and unable to be properly cleaned and sanitized.
      • R7.2N - Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • 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): See comments in inspection report under R 10.3
      • 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.
    • 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 in place to ensure employees implement the facility's policies is ineffective. The policy for purple dot reassessments is currently not being followed, as the employees are behind in the persons in care's reassessments. The policy for employee performance appraisals is not currently being followed, as the site is behind in conducting employee performance appraisals. The restraint policy is not consistently followed, as the documentation is not consistent for the monitoring of persons in care while in restraints.
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system that is in place for the auditing of tub rooms to ensure persons in care are assisted in maintaining health and hygiene is ineffective. LO located unlabelled combs and hair brushes with multiple types of hair present in them. These items were removed from the tub room by the Director of Care (DOC) at the time of the inspection. The system in place to ensure the safe and proper storage of food is ineffective. LO observed unlabelled food items in a neighbourhood fridge that did not contain a date of when it was placed in the fridge, or when it expired. These items were removed at the time of the inspection. LO observed the fridge in the Bistro to be at 10 degrees Celsius, however there was no food currently stored in this fridge.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
      • 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): The system in place for ensuring all medications are safely stored is ineffective. During the physical inspection LO located prescription treatment creams that were not safely stored in the locked cabinet located in the persons in care's bathrooms. LO also located a bottle of Tums in another person in care's room. The DOC removed both items during the inspection.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): See comment under R4.2 and R7.1
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The system in place to ensure that all persons in care's care plans are updated to include information that guide employees in providing care is ineffective. LO reviewed care plans for persons in care who have responsive behaviours, and noted that the plans do not include behavioural interventions to guide the employees. LO reviewed oral care plans, and noted that there are no plans to guide employees in supporting persons in care to maintain their oral hygiene. LO reviewed care plans for persons in care who are at risk for elopement, and noted that there is no plan to guide the employees to mitigate the risk of elopement. LO reviewed a care plan for an individual who had a significant change in their condition, however their care plan did not address the person's recent fluctuation in status.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
      • R10.3G - Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  7. Monitoring

    5 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): July 13, 2017 - The facility's system for ensuring compliance with obtaining signed consent for restraints is ineffective. Persons in care who wear a wander-guard bracelet do not have signed consents in place.
      • R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): July 13, 2017 - The facility does not have a system in place to ensure MARs contain completed documentation for medications administered. LO inspected MARs on three neighbourhoods and found them to be missing employee initials for routine medications administered. The effectiveness of PRNs administered is not consistently documented.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): July 13, 2017 - The facility's system for ensuring compliance with each person in care who has a restraint, has a restraint care plan in place is ineffective. In reviewing the restraint binder LO observed signed consent for a restraint, and the documentation for the monitoring of the person in care while in the restraint, however LO was unable to locate a restraint care plan. The facility does not have a system in place to ensure compliance with the reassessment of restraints and the required documentation. LO was unable to locate documentation showing records are kept for the outcome of the reassessments of the restraints. The facility does not have a system in place to ensure compliance with the documentation for the monitoring of persons in care who wear a wander- guard bracelet. There is no evidence for the monitoring of the persons in care who wear a wander-guard bracelet.
      • R4.3A - Record the type or nature of the restraint used in the person's care plan; 84(a)
      • R4.3B - Record the reason for the use of restraint in the person's care plan; 84(b)
      • R4.3C - 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)
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
      • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): July 13, 2017 - The facility does not have a system in place to ensure compliance with the monitoring of the care and services provided to persons in care. LO observed MARs to be missing employee initials for routine medications administered. LO observed wound care sheets that were incomplete. The wound care system is not being monitored to ensure wound care and the required documentation are being completed. LO observed two TARs with doctor's orders for routine application of prescription cream for a set amount of time and then to be reassessed. TARs were being signed by employees, however care manager and LO unable to locate a documented assessment of person in care's skin. Care plans are not monitored to ensure wander-guard bracelets are included for the persons in care who use them. There is no evidence that the restraints are reassessed and that the outcome of the reassessment is documented as required.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): July 13, 2017 - The facility does not have a system in place to ensure compliance with the monitoring of persons in care to ensure their needs continue to be met. LO observed two TARs with doctor's orders for routine application of a prescription cream for a prescribed amount of time, and to then be reassessed. TARs were signed by employees, however the care manager and LO were unable to find any evidence of assessment of the person in care's skin prior to the cream being applied. Unable to locate a documented assessment during the application phase and when the prescription cream was ordered to be complete. Employees were still signing the TAR, however the nursing notes do not provide indication as to whether the skin is improved, if it is the same or if it is worse. LO observed wound care sheets that were incomplete. They were missing assessments and documentation of dressing changes for 18 days. LO and care manager assessed nursing notes and were unable to locate any documentation of wound care for the 18 days. The last documented nursing note indicated the wound was still present and requiring wound care.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  8. Monitoring

    3 infractions

    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): April 18, 2016 - The facility's system for ensuring compliance with assisting persons in care with maintaining health and hygiene is ineffective. LO observed an unlabelled and used disposable razor, and an unlabelled nail brush sitting beside the sink in the tub room. LO observed an unlabelled comb, hair brush and hair rollers in a tub room. In two person in care's rooms tooth brushes were found laying on top of their hair brushes. LO has referred the facility to their Environmental Health Officer to review their food safety plan. Documented temperatures of neighbourhood fridges were reviewed by LO and it was noted that at times the temperatures were not recorded on the daily log. Three fridges in the neighbourhoods had spilled liquids and spilled food on the shelves and on the bottom of the fridge.
      • 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): April 18, 2016 - The facility's process for ensuring compliance with safe water temperatures is ineffective. LO measured hot water temperatures in the common washrooms in both the upstairs and downstairs neighbourhoods at 55 degrees Celsius. The facility's system for ensuring compliance with safe and secure storage of chemical products is ineffective. LO observed cleaning products that were stored beside food in the neighbourhood's serveries and on the counters leaving it accessible to persons in care. On the second day of the inspection all cleaning chemicals were found stored under the kitchen sinks in the serveries. However there was one servery that was left with the door open leaving the cleaning materials accessible to persons in care. The facility's system for ensuring compliance with safe and secure storage of hazardous items is ineffective. LO observed in a secure unit sharp metal nail files, and razors in persons in care's rooms that were not securely stored. A lighter was located in one person in care's room. The facility's system for ensuring compliance with safe and secure storage of prescription creams is ineffective. LO observed prescription creams in person in care's washrooms in all neighbourhoods that were not securely stored.
      • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • Ensure all medications are safely and securely stored; 69( 3 )(a)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): April 18, 2016 - The facility's system for ensuring compliance with safe and secure storage of prescription creams is ineffective. LO observed prescription creams in person in care's washrooms in all neighbourhoods that were not securely stored. Ensure that all medications in the community care facility are safely and securely stored 69(3)(a)
  9. Monitoring

    8 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Sept 17, 2015-UNRESOLVED from March 02, 2015 - Unable to locate documented reassessment of restraints in some resident's care plans.
      • Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73( 2 ); 75( 2 )(a)(i)(ii)(b)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): Sept 17, 2015 - UNRESOLVED from March 02, 2015 - Staff have been in compliance with the regulations for wheelchair restraints. There was a bed rail restraint that was implemented and not care planned for.
      • Record the type or nature of the restraint used in the person's care plan; 84(a)
      • Record the reason for the use of restraint in the person's care plan; 84(b)
      • Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Sept 17, 2015 -Unable to locate screening residents for pneumococcal or tetanus-diphtheria immunization. Residents and families have not been provided with the information on these immunizations.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
      • Provide information to persons in care regarding the benefits of immunization including pneumococcal, annual influenza and tetanus-diphtheria if appropriate; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): September 17, 2015 - UNRESOLVED form March 02, 2015 - Unable to locate restraint care plans for residents who use bedrail restraints. Fall prevention care plans located that did not contain a date. Some were found to not have been updated when the residents care needs changed.
    • 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): Sept 17, 2015- UNRESOLVED from March 02, 2015- The staff continue to not follow their wound care policy. A resident with a wound was not referred to the dietician, and the referral to OT/PT was 7 days following acknowledgement of the wound. Staff did not follow the restraint policy as bed rails were used without proper monitoring of residents and unable to locate restraint care plans.
      • 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): Sept 17, 2015 - Unable to locate immunization screening in some staff files.
      • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Sept 17, 2015 - Unable to locate documented assessments for the TAR treatments being administered by staff.
      • 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): Sept 17, 2015 - UNRESOLVED from March 02, 2015 - The behaviour care plans in place for some residents are not up to date nor do they contain detailed information to guide the staff. Oral care plans do not contain sufficient information for resident's individual care needs. The resident's charts contained a recreation assessments, however there are no recreational care plans in place. There were residents who had changes in their status and their care plan was not updated. For example the care plan did not include information of skin breakdown or open wounds. Unable to locate Resident's specific information on their individual nutrition care plans.
      • 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)
      • Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
      • Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  10. Monitoring

    15 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): March 02, 2015 - LO unable to locate a doctor's written consent for restraints in a Resident's chart.
      • A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74(1)(a)(b)(i)(ii)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): March 02, 2015 - The alternatives that were trialed prior to the use of restraints is not documented in the Resident's care plans . -The staff are not documenting the monitoring of Residents while they are in the restraints. -LO was unable to locate the results of the reassessments of the restraints on the restraint care plans.
      • Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): March 02, 2015 - There was a wheel chair stored in a visible walk through storage area that was stated to be an extra or emergency wheel chair. It was visibly dirty and there was no cushion on it. -There is a TV stand in upper Apple neighbourhood that is chipped and appears to need refinishing or replacing.
      • 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): March 02, 2015 - The staff are not routinely monitoring the Resident's throughout the use of the restraints. -The restraint care plans do not include all the alternatives to restraints that were trialed. -The restraint care plan does not indicate the duration of the restraint use. -Several Resident's care plans had incomplete falls prevention plans.
      • Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73(1)(c)
      • Ensure all alternatives to the use of a restraint have been considered and either implemented or rejected; 73(2)(a)
      • Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73(2)c
      • Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81(3)(e)(i)(ii)(iii) (Show More)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): March 02, 2015 - The facility is not regularly monitoring the care and services it provides to ensure that requirements for the Act and the Residential Care Regulations are being met.
      • 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): March 02, 2015 - The restraint policy does not guide the staff to document the required information in a restraint care plan. March 02, 2015 - The staff are not following the facility's restraint policies as they are not documenting the monitoring of the Resident throughout the use of the restraint. -The staff are not following their wound care policy. The staff did not document in the progress notes the condition of the wound or treatments being provided. The wound care sheet was not consistently completed. There was no referral to OT/PT therefore no assessments or intervention was put into place. The dietician was not made aware of the wound, so there was no nutritional assessment or dietary changes made. The Resident's care plan was not updated to indicate there was a wound, nor was there any recent skin assessments documented or Braden scales.
      • 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): July 16, 2014 - UNRESOLVED- Staff files are missing work history, character references, performance evaluations and food safe certificates. March 02, 2015- Staff files were not inspected today as the manager reports they are approximately half way through the files and performance appraisals. They are auditing each staff file as they complete the performance appraisals for the staff member. The staff are then given one week to return the missing documentation to the manager. March 02, 2015 - Staff did not document a change in status of a Resident with a wound, Staff did not follow through with proper notification of the multidisciplinary team in regards to a Resident with a wound. Staff did not perform the proper assessments and documentation of the Resident with a wound. There were 10 incomplete resident care plans in one neighbourhood.
      • Obtain character references for all employed persons; 37(1)(b)
      • Obtain a record of work history for all employed persons; 37(1)(c)
      • 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 have the necessary training and experience or demonstrate the necessary competence to carry out duties; 40 (3)
      • 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)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): July 16, 2014-UNRESOLVED - There is missing monthly weights from resident's charts. March 02, 2015 - There are two neighbourhoods that do not have locking doors to the nursing stations where the resident's charts are stored.
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83(4)(a)(c)
      • Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): March 02, 2015 - Please see above comments under staffing 3.1
      • Keep employee character references; 86(b)
      • 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): March 02, 2015 - There was a note taped onto the outside of a Resident's bedroom door that disclosed personal information. Staff unaware of who had left the note. It was removed from the door and relocated to the bathroom during the inspection.
      • 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 (3)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): March 02, 2015 - Unlabelled, non- resident specific items such as razors, nail clippers, nail files, combs, brushes, a tooth brush, were located in all tub rooms, -Cheese and dietary cookies that are supplied to the neighbourhoods are not dated. -Two fridges in the upstairs neighbourhoods were found to be dirty and required cleaning.
      • 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): March 02, 2015 - Heavy damage was noted to the lower walls in both neighbourhoods of upper Bartlett and upper Apple. -The menu that was posted in several neighbourhoods was on the wrong week.
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
      • Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35(1)(b)
      • Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 (4)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): March 02, 2015 - There were prescription creams located in two different resident rooms which did not contain a label from the pharmacy, and therefore were not prescribed by the doctor.
      • Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69(1)(a)(b)
      • Administer only medications prescribed or ordered by the medical or nurse practitioner; 70 (1)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): March 02, 2015 - There was no documentation of regularly monitoring a resident who had a wound to determine if their needs were 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): March 02, 2015 - There were 10 care plans found for residents that were incomplete. -There was a resident with a change in status (a wound) and the care plan was not updated. -Care plans are not being monitored to ensure that they are up to date when there are changes in resident's status.
      • 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)
      • 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)