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Henry M. Durand Manor

803 9 Ave S Golden BC V0A 1H0 · Residential Care - Licensing

10 inspections

  1. Routine Inspection Follow-up

    1 infraction

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): R1.1W - Based on a review of the compliance plan accepted by Licensing on October 8, 2025, the supporting documentation, and on‑site discussions, it is noted that the scheduled audits outlined in the plan are not implemented and are not currently being carried out as specified. The plan identifies multiple weekly and bi‑weekly audits, as well as a nursing meeting to be held in mid‑October 2025. Documentation indicates that audits are completed on December 29, 2025, and March 3, 2026; however, the required audit frequency outlined in the plan is not maintained. During on‑site discussions, it is confirmed that the October 2025 nursing meeting does not occur and is instead scheduled for April 2026 to include recently hired nursing staff. Failure to implement the compliance plan in its entirety as submitted and accepted by Licensing increases the risk of continued non-compliance with regulatory requirements and may result in ongoing or repeated contraventions. Without a process to complete and review audits, the risk that ineffective practices or non-compliance will go unidentified and unaddressed increases, potentially impacting the health and safety of persons in care. Submit by April 10, 2026, a new written plan outlining how the contravention related to ensuring the care and services provided is regularly monitored has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 61 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
  2. Routine Inspection

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): R1.1W - During a review of the physical environment and documentation related to care and services, the existing self-monitoring system was noted to be limited in scope and ineffective in consistently identifying gaps. Gaps were noted in documentation on multiple persons in care immunization status, where immunization forms were incomplete or left blank with no system in place to ensure follow up. Care plan binders had not been consistently reviewed to confirm that all pertinent and up to date information was available for staff reference. Blank forms were noted on the walls throughout the building with no system in place for identifying or correcting the identified gap in completion. Without a system for self-monitoring, gaps in documentation and care practices may go undetected, leading to incomplete records, outdated care plans, and potential non-compliance with regulatory requirements. Submit by October 2, 2025, a written plan outlining how the contravention related to regularly monitoring the physical environment and the care and services provided has been addressed. The plan must also detail the systems and processes that will be implemented to support the review, and if necessary, modification of care plans as required by Section 61 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • 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): During a review of wound care plans it was noted that the active wound care plans did not include clearly defined instructions for frequency of completion.
      • 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.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): R3.1AA - During a review of person in care's medication administration records it was noted that the effectiveness of as needed (PRN) medications was not documented. There is a risk that, without documentation of the effectiveness of as-needed (PRN) medications, the care team will not have adequate information to evaluate whether the medication is appropriate or effective for the person in care. Submit by October 2, 2025, a written plan outlining how the contravention related to documentation of PRN effectiveness has been addressed. The plan must also detail the system and process that will be implemented to support ongoing monitoring of Section 68(4) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 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): R10.3A - During a review of wound care plans it was noted that the active wound care plans did not include clearly defined instructions for frequency of completion. The absence of clear written instructions regarding the frequency of wound care increases the risk of inconsistent treatment and potential delays in care. It also presents a risk of miscommunication among staff and a lack of clarity regarding care responsibilities. Submit by October 2, 2025, a written plan outlining how the contravention related ensuring a care plan is developed taking into account the unique physical needs has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 81(2)(b) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward. R10.3J - During a review of a pain management flowsheet clear directions were included for employees to complete documentation once per shift. It was noted that the flowsheet did not contain any documentation for the month of August. There was no system in place for identifying or correcting the identified gap in completion. There is a risk that, without a system to ensure care plans are implemented as written, persons in care will not receive services aligned with their assessed needs as well as potential for inconsistent care delivery, adverse health, safety or wellbeing outcomes for persons in care and non-compliance with legislative requirements. Submit by October 2, 2025, a written plan outlining how the contravention related to ensuring care plan implementation has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 81(4)(a) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  3. Routine Inspection

    3 infractions

    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The system to ensure a pharmacist records all medications on the person in care's medication administration record is ineffective. During a review of treatment administration records, multiple records contained medications that were hand written, and not recorded by the pharmacist.
      • R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
    • 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 professional at least once every year is ineffective. During the inspection the Licensing Officer reviewed two persons in care's charts with no documented offer to be examined, or an examination having been completed by a dental health care professional in the past year. The two care plans contained a section to record most recent appointment, as well as the next appointment, both of which were blank. The system to ensure ongoing tray service is approved and reassessed at least once every 30 days by the person in care's medical or nurse practitioner is ineffective. During a random chart audit a person in care currently admitted for respite care, for a duration greater than 30 days, had ongoing tray service identified in their care plan. Ongoing tray service had been provided to the person in care with no documented approval of, or reassessment for the ongoing need of that service as required by R10.2V. The Licensing Officer communicated this observed contravention to the Licensee during the inspection and provided education around requirements of all persons in care, including respite care. The Licensing Officer reviewed documentation for ongoing tray service approval and reassessment for permanent persons in care completed as per the legislative requirements. R10.2V is a re-occurring contravention from Oct 2021 inspection.
      • R10.2H - Encourage persons in care to be examined by a dental health care professional at least once every year; 54( 3 )(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): The system to ensure the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan is ineffective. During a random chart audit, two persons in care's care plans stated that a reassessment of a depression scale be completed every 4 months. There was no documented record of the reassessments being completed every 4 months.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  4. Routine Inspection

    10 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system to ensure all medications administered are recorded is ineffective. This was evidenced by incomplete Treatment Administration Records (TARs). At the time of this inspection the licensee has initiated internal audits of the treatment administration records.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): The system to encourage persons in care to participate in the current program of activities is ineffective. During a random chart audit it was identified that there is no current record of participation, or encouragement to participate in the program of activities.
      • R8.1B - Encourage persons in care to participate in the program of activities provided (Does not apply to Hospice); 55( 1 )(b)(i)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The licensee does not currently have a system to ensure the most recent routine inspection record is displayed in a prominent place within the facility.
      • R1.1O - Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
    • RB1.5 - Are persons in care informed on how to express concerns or make complaints to the medical health officer or to the Patient Care Quality Office prior to admission?
      • Observation(s): The licensee does not currently have a system in place to advise persons in care, their parent or representative how to express concerns or make complaints to licensing.
      • RB1.5A - Inform persons in care on admission on how to express concerns or make complaints to the medical health officer.
    • RB1.17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
      • Observation(s): The licensee does not currently have a system to ensure the most recent routine inspection record is displayed in a prominent place within the facility.
      • RB1.17A - Post the most recent routine inspection in a prominent place.
    • 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): The licensee currently does not currently have a system in place to ensure persons in care who leave the facility independently have a plan in place.
      • 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 licensee does not currently have a system in place to advise persons in care, their parent or representative how to express concerns or make complaints to licensing.
      • R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system to ensure each person in care's weight is recorded monthly is ineffective. It was noted during inspection that monthly weights were inconsistently recorded.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The licensee currently does not have a system in place to ensure persons in care who leave the facility independently have written documentation containing the facility name, and emergency contact information. It was noted during the inspection that a person in care who leaves independently does carry personal identification.
      • 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 )
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The licensee currently does not currently have a system in place to ensure persons in care who leave the facility independently have a plan in place specific to their abilities, and needs.
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
  5. Routine Inspection

    3 infractions

    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): It was noted during the inspection that the system for ensuring fridge temperatures are monitored consistently was ineffective.
      • 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): It was noted during the inspection that the system for ensuring bathrooms have a door with a lock that can be opened from the outside in case of an emergency was ineffective. Previous exemption for Section 30(a) of the Residential Care Regulations (RCR) expired in August 2021. Licensee currently preparing a new exemption request for Section 30(a) of the RCR.
      • R7.1AB - Bathrooms must have a door with a lock that can be opened from the outside in case of an emergency; 30(a)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It was noted during the inspection that the system for obtaining written consent for release or removal of a person in care from the facility was ineffective.
      • R10.2Q - Only a parent or representative or a person authorized in writing by that person can release or remove a person in care from the facility; 58( 1 )(a)(b)
      • 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)
  6. Routine Inspection

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Upon discussion of incident reporting and care plan implementation, Licensing Officer noted that the system for ensuring that the facility regularly monitors the physical environment and the care and services provided is ineffective.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Emergency drills are were not done in the months of June, August and September.
      • R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Two areas were noted on this inspection requiring attention to ensure the hazardous materials are not accessible to persons in care: -the old shower room not intended for persons in care to access -lounge area (currently under construction) that contained numerous items and exposed electrical outlets
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
  7. Monitoring

    7 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Treatment administration records reviewed during this inspection were observed as sporadically charted, different codes were utilized that were not listed on the document legend, as well as many missed charting days. Please review treatment documentation procedures to ensure all treatment are charted. In your response include what changes have been made to the procedure as well as how the charting will be audited to ensure compliance. PRN charting observed during this inspection was inconsistently charted in regard to the outcome/result of the PRN medication. Inform Licensing on what systems/audits will be put in place to ensure PRN charting is complete.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): An incident reporting procedure that included the reportable incident types - Residential Care Regulation Schedule D - was not available at the time of this inspection. A discussion occurred regarding reportable incident types, unexpected illness IR's appear to be under reported. Facility will update incident reporting procedures, include in your response how staff will be trained on the updated procedures.
      • 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)
    • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Currently PIC's do not have individual recreation care plans in place, once care plans are developed, ensure the program of activities is designed to meet the needs of the persons in care. Inform Licensing on how the program of activities will be continually audited by the facility recreation program to ensure it is meeting the individual recreation needs of the person in care.
      • R8.1A - Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55( 1 )(a)(i)
    • RB1.13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): Currently PIC's do not have individual recreation care plans in place, once care plans are developed, ensure the program of activities is designed to meet the needs of the persons in care. Inform Licensing on how the program of activities will be continually audited by the facility recreation program to ensure it is meeting the individual recreation needs of the person in care.
      • RB1.13A - Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Some bedrooms in the facility have bathrooms that do not have a door, inform Licensing on what steps will be taken to follow-up on this issue. A servery door was observed as unlocked during this inspection with no staff present in the area, this could lead to food safe concerns or potentially hazardous materials if a PIC or visitor accessed the food prep area. Corrected at the time of inspection.
      • R7.1AB - Bathrooms must have a door with a lock that can be opened from the outside in case of an emergency; 30(a)
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Some PIC's who have been assessed as an elopement risk do not have ID. Ensure all PIC's who may leave the facility without notifying staff have some type of ID which includes their name, the facility name and emergency contact information. Include in your response how ID will be audited to ensure PIC's who have been assessed as requiring it, have it in place.
      • R10.2M - Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56( 3 )(a)(b) (Show More)
    • 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): Individual recreation plans are currently not in place. Inform Licensing on how the plans will be created and updated as required/needed. Also include in your response what systems and audits will be put in place to ensure all PIC's have a current recreation plan in place.
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
  8. Monitoring

    2 infractions

    • RB1.18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): Licensing has observed the front courtyard area which has varying surfaces(concrete, pavement, gravel, and dirt) with uneven transitions. The walkways are unkempt, piles of debris, uneven and cracked sidewalks with portions raising. These are tripping hazard for persons in care (PIC) and potential barrier for PIC to access this area. The exterior of the building is noted to have an awning which is torn, siding which has missing paint and is well worn, and the gardens have old bushes which have not been cleaned up. The interior of the facility is noted to have holes in the walls and chipped paint in bathrooms in PIC rooms, hallways, common areas and the dining room. Multiple bathroom counters in PIC bedrooms noted to be stained and warped.
      • RB1.18A - Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing has observed the front courtyard area which has varying surfaces(concrete, pavement, gravel, and dirt) with uneven transitions. The walkways are unkempt, piles of debris, uneven and cracked sidewalks with portions raising. These are tripping hazard for persons in care (PIC) and potential barrier for PIC to access this area. The exterior of the building is noted to have an awning which is torn, siding which has missing paint and is well worn, and the gardens have old bushes which have not been cleaned up. The interior of the facility is noted to have holes in the walls and chipped paint in bathrooms in PIC rooms, hallways, common areas and the dining room. Multiple bathroom counters in PIC bedrooms noted to be stained and warped.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • R7.1AH - Lounge and recreational areas must be accessible to persons in care at all times except during cleaning and maintenance; 34 ( 13 )
  9. Monitoring

    7 infractions

    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Licensing observed uneven sidewalks with cracks which had loose gravel throughout, creating a potential falls risk. This is a ongoing contravention from previous inspection 11-Aug-2015.
      • Ensure that persons in care who require mobility aids can access all areas intended for use by persons in care; 14 ( 1 )
      • Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
      • Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • 9.2 Does the supervising pharmacist consult with employees respecting medication interactions and other problems related to medication?
      • Observation(s): Licensing observed there is no MSAC meetings occurring regularly. Manager reports facility has undergone changes to the Pharmacy process.
      • Appoint a supervising pharmacist to consult with employees respecting medication interactions and other problems related to medication; 68( 2 )(c)
    • 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): Licensing observed uneven sidewalks with cracks which had loose gravel throughout, creating a potential falls risk. Licensing observed very long grass in the inner courtyard, a path of overgrown bushes, a bag of leaves, and a broken gazebo is left in the corner area of courtyard, which makes it inaccessible by wheelchair/walker. There is 2 chairs and a small umbrella, which does not provide adequate shelter from the sun and inclement weather. These are ongoing contraventions from the previous inspection 11-Aug-2015.
      • 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?
      • Observation(s): Licensing observed that the large white board in the conference room, which contains private and confidential information of PIC is visible to PIC, family and visitors when the door is open.
      • Respect personal privacy and keep records and personal information confidential.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing observed that the physical contraventions listed in this report are ongoing since previous inspection 11-Aug-2015. The licensee's monitoring process to monitor the physical environment is ineffective.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing observed that the large white board in the conference room, which contains private and confidential information of PIC is visible to PIC, family and visitors when the door is open.
      • 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
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing observed very long grass in the inner courtyard, a path of overgrown bushes, a bag of leaves, and a broken gazebo is left in the corner area of courtyard, which makes it inaccessible by wheelchair/walker. There is 2 chairs and a small umbrella, which does not provide adequate shelter from the sun and inclement weather. This is a ongoing contravention from previous inspection 11-Aug-2015.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Provide outside activity areas that have comfortable seating including a reasonable amount of shelter from sun and inclement weather; 36 ( 1 ) (c)
  10. Monitoring

    11 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Missing signatures on treatment record for multiple persons in care.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Unable to locate tuberculosis screening on person in care file.
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Visitor bathroom noted to be unlocked and accessible to persons in care, no signalling device in this bathroom.
      • Provide a monitoring system or signalling device that is appropriate to the needs of persons in care; 19( 1 )(a)
    • 8.1 Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Tracking of invitation to and participation in activities is inconsistent/inadequate.
      • Encourage persons in care to participate in the program of activities provided (Does not apply to Hospice); 55( 1 )(b)(i)
    • 8.2 Does the program of activities support individualized care plan requirements?
      • Observation(s): Recreation programming provided is inadequate in terms of variety and frequency. Program types are not sufficient for the varying interests and abilities of all persons in care.
      • Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55( 1 )(a)(ii)
    • 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): Emergency policies including fire and evacuation procedures indicate last review date as 2013.
      • Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Unable to locate admission height on multiple person in care files.
      • Record the height and weight of each person in care on admission; 49 ( 2 )
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Snack choices do not consistently contain items from 2 food groups. There are currently no routine times for snack rounds, or designated staff to complete this task.
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
      • Ensure snacks are provided at times to meet needs of the persons in care (Does not apply to Child and Youth Residential); 64( 1 )(d)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Communal/unlabelled hygiene products and cream located in shared bathrooms and tubroom. Food fridge temperatures not consistently monitored.
      • 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): Uncovered hot water spigot in servery that is accessible to persons in care. Multiple bathroom counters in person in care bedrooms noted to be stained and warped; secured yard and walkway unkempt, path overgrown with bushes making it inaccessible by walker/wheelchair, piles of debris; patio bricks sinking/lifting creating hazard for falls; courtyard off secure unit noted to have cracked sidewalks, portions raised creating hazards for falls, loose gravel; internal courtyard noted to have lifted rubber slabs creating hazards for falls. Unlocked hazards noted including medicated creams and wound products in person in care bedrooms, plant preservative in person in care bedroom, unlocked laundry area, unlocked servery areas, and unlocked tubroom containing chemical cleaners. Outdoor area off secure unit has no seating and internal courtyard does not provide shelter from sun/precipitation. Weekly menu displayed in 1 of 2 diningrooms only and is dated November 2014.
      • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
      • Provide outside activity areas that have comfortable seating including a reasonable amount of shelter from sun and inclement weather; 36 ( 1 ) (c)
      • Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
    • 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): Unable to locate oral care plans on multiple person in care files. Unable to locate recreation care plans on multiple person in care files.
      • Care plans must includes an oral health care plan; 81( 3 )(b)
      • Care plans must include a recreation and leisure plan; 81( 3 )(d)