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Heritage Square

3904 27 St Vernon BC V1T 4X7 · Residential Care - Licensing

9 inspections

  1. Routine Inspection

    3 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The system to ensure that staff are following the instructions in the care plan respecting the monitoring requirements are ineffective. It was observed that restraint monitoring checklists were sporadically charted. The use of a restraint without consistent monitoring increases the risk to the person in care's physical safety and emotional dignity. Submit by May 08, 2026, the plan that will be implemented to come into compliance with Section 73(2)(b)(ii) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R10.4F - Employees administering a restraint must follow any instructions in the care plan of the person in care respecting the use of restraints; 73( 2 )(b)(ii)
    • 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 all policies and procedures are followed is ineffective. A review of the Resident care flow sheets and Behavioural monitoring forms were not fully completed as per policy. Incomplete checklists and monitoring sheets may indicate that processes and checks were not completed as required. This was also a contravention on the previous inspection. Submit by May 08, 2026, the plan that will be implemented to come into compliance with Section 85(1)(d) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • 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): The system to ensure that all rooms and common areas are maintained in a safe and clean condition is ineffective. The hallway carpets were observed to be stained and dirty throughout the facility. It was also observed that windows throughout the facility had not been cleaned, with stains noted on an exit door into the courtyard. Not maintaining a clean environment on a regular basis poses a risk to the health and safety of persons in care. Submit by May 08, 2026, the plan that will be implemented to come into compliance with Section 22(1)(c) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
  2. 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): The system to ensure that policy and procedures are reviewed yearly is ineffective. A review of the emergency response manual identified policies dated January 2022, with no evidence that these have been reviewed / revised yearly. All policy and procedures should be current as these are guidelines for all staff to implement. Submit by April 25, 2025, evidence that the facility has a process to ensure that all policy and procedures are reviewed / revised on a yearly basis. The system to ensure that all policies and procedures are followed is ineffective. A review of the monitoring log binder identified checklists for restraint monitoring and turning schedules which were not fully completed as per policy. Incomplete checklists may indicate that processes and checks were not completed as required. Submit by April 25, 2025, evidence that you are implementing a system to ensure that checklists are completed as per the policy and procedures.
      • 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)
    • 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. Not meeting minimum nutritional requirements may pose health risks. Submit by April 25, 2025, evidence that your menu includes snacks that contain at least two 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system for maintaining the physical environment is ineffective as noted by the observed deficiencies. Wall damage in several locations in a bedroom and the bathroom. Broken shelving in a bedroom. Wall repair in hallways not painted. Paint was also observed to have peeled off an exit door as well as on walls in several locations within the facility. Regular maintenance is important to ensure the ongoing health, safety and dignity of persons in care. Submit by April 25, 2025, evidence that you have a plan to address the identified deficiencies as well as implementing a system of maintaining the physical environment in a timely manner. While conducting an inspection of the facility, it was observed that the designated smoking area was in an unsecured area posing a potential health & safety risk to persons in care. The designated location can currently be accessed by non-residents posing a safety concern to persons in care. Submit by April 25, 2025, evidence that you are securing the area to protect person in care.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • R7.1AO - Ensure the outside activity area is secured by a fence or other means, if necessary to protect the health and safety of persons in care; 36 ( 2 )
  3. Routine Inspection

    3 infractions

    • 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 review of a Care plan identified a consent form that was not completed or signed.
      • R4.1I - 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system to ensure that persons in care are encouraged to see a dental professional at least once a year is ineffective. A review of Care plans did not provide evidence that this has occurred. The system to ensure ongoing Tray service is reassessed every 30 days is ineffective. A review of care plans identified that a person in care who receives Tray service which is not care planned for in the Care plan and no reassessments completed.
      • 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 review / revise care plans is ineffective. The smoking care plan for a person in care was not revised as a result of changes made to the smoking plan for the individual. The system to ensure that the care and supervision of persons in care is consistent with the terms of the care plan is ineffective. A review of the monitoring binder, containing check sheets for Safety checks, Turning schedules, Oxygen monitoring as well as Toileting schedules were all sporadically missing signatures.
      • 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)
      • 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

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Treatment administration records reviewed were charted sporadically. This contravention was also noted on the previous inspection completed in March 2022.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system to monitor fridge temperatures is ineffective. It was noted on several fridges, there were missed days of recorded temperatures.
      • 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): Coffee carafe and water kettle observed in dining rooms that allows PIC's to have potential access to hot water over 49 degrees Celsius. This contravention was also noted on the previous inspection completed in March 2022. It was observed in several areas of the dinning rooms that walls were in a state of disrepair, there was a cupboard with a door missing in one kitchen area and in another dining area there was a ceiling in need of repair. Weekly menu was not posted in a prominent area of the dining room and the print size was not appropriate for the PIC's.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • 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): The system for monitoring was ineffective, it was noted in a Falls Risk Care plan and an Elopement Risk Care plan that monitoring was not recorded or was incomplete.
      • 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

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Please review facility treatment administration records/process to ensure all treatments are being completed and charted according to the orders in place.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(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?
      • Observation(s): Facility policy indicates care plans posted in person in care washrooms will be reviewed/updated at least quarterly, one posted care plan observed during this inspection was last charted as reviewed in August 2021.
      • R2.1P - 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Regular staff performance reviews are overdue at this time, please inform Licensing on what steps will be taken to ensure reviews are caught up and kept on schedule moving forward. Currently the Food Service Manager does not have membership to the Canadian Society of Nutrition Management and is not a dietician. Please inform licensing on what steps will be taken to resolve this contravention.
      • 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)
      • R3.1S - 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Coffee carafe and maker observed in the dining rooms in an area that allows PIC's to have potential access to hot water over 49 degrees Celsius.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
    • 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): Ensure care plans for persons in care (PIC) who are able to leave the building independently include specific details to help staff support them. ( How long is PIC able to safely leave prior to staff following up?, What steps are staff to take if PIC does not return by specified time?, does PIC have ID? Do they have a cell phone? etc...).
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
  6. 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): There is no system in place to orientate employees to the Residential Care Regulation and the Community Care and Assisted Living. The facility does not have a policy in place for the orientation of employees to the Residential Care Regulation and the Community Care and Assisted Living Act.
      • R2.1T - 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system that is in place to monitor the physical environment to ensure it is maintained in a safe condition is ineffective. During the physical inspection of the facility Licensing Officer noted a piece of flooring in a person in care's room that had lifted creating a tripping hazard. The Nurse Manager stated she would secure the flooring with duct tape following the inspection until maintenance could attend the facility to repair it.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The system in place to ensure that the employees are following persons in care's care plans is ineffective. LO reviewed a person in care's care plan that stated daily wound care and dressing changes were to be completed. LO reviewed the documentation for the wound care to assess if the care plan was being followed. It was noted that the wound care sheet was not consistently documented on nor were there progress notes to indicate daily wound care was being completed. LO reviewed 6 persons in care's care plans and noted that not all areas of the care plans contain person specific information. LO noted the dietary information documented by the dietician in the nutrition section of the chart was not consistently documented in the person in care's care plans. For example a nutrition care plan stated to offer the person in care their nutritional preferences, however the preferences were not documented in the care plan or on their my day.
      • 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
  7. Monitoring

    2 infractions

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): November 23, 2017 - The process that is in place to ensure that the employees who are responsible for the preparation and handling of food, have the proper documentation in their files as evidence of ongoing approved training is ineffective. LO reviewed a Health Care Aide's file who handles food. LO observed a Serving it Right Certificate. This certificate is not equivalent to Food Safe Level 1 that is required as per the facility's policy.
      • R3.1R - Ensure employees responsible for the preparation and delivery of food receive ongoing education respecting the preparation and delivery of food, nutrition, and if required, assisted eating techniques; 44 ( 1 )(b)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): November 23, 2017 - UNRESOLVED - The facility's system for ensuring compliance with obtaining an up to date record for persons in care immunization status is ineffective. Following the 2016 monitoring inspection the facility put a system in place for the screening of persons in care's immunization status. Upon LO reviewing a person in care's chart, it was noted that their immunization screening record had 'NO' recorded for pneumococcal, and tetanus/diphtheria vaccines. The Licensee was unable to locate documentation to indicate if the immunizations had been offered, administered, or refused by the person in care. The system in place to ensure that each person in care's monthly weight is recorded is ineffective. LO reviewed 5 persons in care's monthly weight records, and found that the weights are not consistently recorded every month for each person in care, and there was no documentation to indicate that the person in care had refused to be weighed.
      • R4.1C - Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78( 1 )(a) Director of Licensing Standards of Practice: Immunization records
      • 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)
  8. Monitoring

    10 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): November 25, 2016 - The facility's system for ensuring compliance with keeping a record of the results from the reassessments for restraints is ineffective. The facility is reassessing the restraints quarterly, however the results of the reassessments are not recorded on the restraint care plan.
      • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): November 25, 2016 - The facility's system for ensuring compliance with providing persons in care and their families with information in regards to immunizations is ineffective. The facility is currently not informing the persons in care and their families on the benefits of all immunizations recommended for persons in care.
      • R6.2C - 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
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): November 25, 2016 - The facility does not have a system in place for ensuring compliance with maintaining furniture in a clean condition. A blue couch located in a hallway was found to be visibly dirty with food and fluid stains.
      • R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • 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): November 25, 2016 - LO reviewed a person in care's care plan and it did not reflect their current status of high falls risk. There was no falls care plan in place to mitigate the risk of future falls.
      • 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): November 25, 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 progress notes and found the person to have suffered several falls. The employees did not follow the facility's falls policy. Post falls assessments were not consistently documented, there was no falls care plan in place, the person in care had not been referred to PT/OT for falls assessment, the Scott Falls assessment had not been updated since admission.
      • 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): November 25, 2016 - The facility's system for ensuring compliance with ensuring at all times persons in care have access to an employee with a valid CPR certificate is ineffective. An employee file was reviewed and found to have an expired first aid certificate. This employee is required to have an up-to-date first aid certificate as per facility policy. The employee was already registered for a course in early December 2016. The employees We Care manager stated that the employee would only be scheduled to work shifts with an employee who has their current first aid certificate until their first aid is updated.
      • R3.1O - 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): November 25, 2016 - The facility's system for ensuring compliance with having an up to date record of all persons in care's immunization status is ineffective. LO reviewed a sampling of 5 persons in care's charts, and it was observed that immunization screening was not consistently completed.
      • R4.1C - Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78( 1 )(a) Director of Licensing Standards of Practice: Immunization records
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): November 25, 2016 - The facility's system for ensuring on going compliance with the monitoring of the personal hygiene items located in the tub room is ineffective. An unlabelled hair brush and comb with different colors of hair in them were located in the tub room.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): November 25, 2016 - The facility's system for monitoring the common areas to ensure compliance with being in a good state of repair is ineffective. The carpets in the facility's hallways were noted to appear stained and dirty. The manager stated that they were professionally steam cleaned one month prior.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • 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): November 25, 2016 - The facility's system to ensure compliance with reviewing and updating care plans upon a change in a person in care's condition is ineffective. LO reviewed a person in care's care plan. It had not been updated to reflect their current status and their increased falls risk, nor did it contain any measures taken to mitigate the risk of future falls.
      • 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)
  9. Monitoring

    4 infractions

    • 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 preparedness manual did not include a policy in regards to responding to a power outage.
      • Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51(1)(a)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): In the sampling of staff records reviewed, several staff records were noted to be missing immunization and tuberculosis control records.
      • 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): There were no consents to call a medical or nurse practitioner or ambulance on record in the sampling of person in care records reviewed. This remains outstanding from the last inspection.
      • 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)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Staining noted on the floor of a persons in care room. The follow up date for this to be completed is June 10, 2015 as the manager stated that the flooring will most likely need to be replaced. Cleaning supplies were found in a cupboard underneath the sink in one of the dining rooms. This particular cupboard does not have a lock installed on it.
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35(1)(c)