Hearthstone Manor
2800 40 St Vernon BC V1T 6J7 · Residential Care - Licensing
5 inspections
- Routine Inspection
3 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): A review of Care plans which identified the use of a bedrail restraint, did not have any evidence of a Restraint agreement. Failure to have restraint agreements may compromise the health, safety and dignity of persons in care. Submit by April 03, 2026, the plan that will be implemented to come into compliance with Section 74(1)(b) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
- 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)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): The system to ensure that restraint agreements are reassessed is ineffective. A review of a restraint agreement identifying the use of a restraint which was not reassessed as per the time period specified. Failure to reassess restraint agreements as specified may compromise the health, safety and dignity of persons in care. Submit by April 03, 2026, the plan that will be implemented to come into compliance with Section 75(3)(a) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
- 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)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): The system to ensure that food substitutions are from the same food group and have a similar nutritional value is ineffective. It was observed that the food substitution list had items that were not from the same food group, for example soup was substituted by sausage. Not meeting the nutritional requirements can potentially impacts nutritional health outcomes of persons in care. Submit by April 03, 2026, the plan that will be implemented to come into compliance with Section 62(2)(d) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
- R5.1I - Provide substitutions from the same food group and have a similar nutritional value; 62( 2 )(d)
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- 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): The system to ensure that policy and procedures are reviewed is ineffective. A review of the policy and procedure manual identified that snacks contain one food group, contrary to RCR 62(2)(b), which states that snacks should contain at least two food groups.
- R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): The system to ensure that persons in care have consented to the facility calling a medical practitioner or ambulance in case of an accident or illness is ineffective. A random review of a care plan binders identified missing consent forms.
- R4.1L - Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Routine Inspection
3 infractions
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): The system to ensure that employees are trained in the implementation of Emergency plans is ineffective. Staff have not practiced the packing of all necessary equipment and use of transportation for evacuation purposes.
- R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): The system to ensure that snacks contain at least two food groups is ineffective. A review of the menu contained daily snacks with only one food group.
- 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): The system to encourage persons in care to be examined by a dental health care professional at least once per year is ineffective. There was no documented evidence to indicate whether a person in care had been encouraged but declined to be examined by a dental health care professional.
- R10.2H - Encourage persons in care to be examined by a dental health care professional at least once every year; 54( 3 )(a)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Routine Inspection
0 infractions
- Routine Inspection
4 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): MAR's reviewed during this inspection, PRN documentation for the effectiveness of the medication was noted as inconsistently charted.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Fire and evacuation drills are completed on a regular basis, ensure other code drills are practiced on a regular basis to ensure staff are up to date on procedures.
- R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Facility changed ownership in September 2020, since that time a Family and Resident Council meeting has not occurred. Ensure steps are taken to establish a Family and Resident Council. Ensure ongoing room tray service is approved by medical or nurse practitioner, and reassessed by the medical or nurse practitioner or dietician at least every 30 days.
- 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)
- R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): Recreation plans are currently being reviewed/updated, some of the older plans are still in need of updating. Current recreation schedules do not include recreation programming on the weekends, ensure recreation care plan development includes a review of whether programming would be beneficial 7 days a week.
- R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?