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Hillside Village

2891 15 Ave NE Salmon Arm BC V1E 1G9 · Residential Care - Licensing

15 inspections

  1. Substantiated complaint

    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): Substantiated Finding - RCR s. 85(1)(d): A review of medication administration records (MAR) between April 2025 and April 2026, for one person in care (PIC), reveals there are several instances of PRN (as needed) medication effect not documented, and several instances of missing signatures for scheduled medications with no documented reasoning. The facility policy entitled "Medication Administration Record" was not implemented by employees. Page two of the policy states that, "[f]or PRN - when needed medications, employees will document the administration on the back of the MAR, including the reason for use and effectiveness..." and "[f]or all regularly administered medications, employee will initial the appropriate space on the resident's MAR immediately after the medication is taken..." When a licensee does not ensure that policies are implemented by employees, by documenting PRN effect and ensuring scheduled medications are signed for, this increases risk of medication error for PICs. A written corrective action plan, outlining how the Medication Administration Record policy will be implemented by employees, was received and accepted by Licensing on June 29, 2026. This plan details the system and process that has been implemented to support the ongoing monitoring of RCR s. 85(1)(d), thereby ensuring sustained compliance moving forward.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Unsubstantiated Finding - RCR s. 70(1): Allegation that a PIC is being given medication and they don't know what it is for, or if their doctor ordered it. Evidence reviewed does not substantiate that the PIC was given medication that they did not know what it is for, or if their doctor ordered it. Documentation reveals that the PIC continued working with their medical practitioner, received medications as prescribed, and that employees provided education to PIC regarding the prescribed medication. Substantiated Finding - RCR s. 71(a): A review of medication administration records, for one PIC, reveals three instances within April 2026, where employees made handwritten changes to the directions for use of a medication. Employees made handwritten changes to the directions for use of a medication as observed within the indicated medication administration records. When a licensee does not ensure that handwritten changes to the directions for use of a medication are not made, this increases risk of medication error for PICs. A written plan, outlining how handwritten changes to the directions for use of a medication are not made, was received and accepted by Licensing on June 29, 2026. This plan details the system and process that has been implemented to support the ongoing monitoring of RCR s. 71(a), thereby ensuring sustained compliance moving forward.
      • R9.1H - Ensure employees do not make handwritten changes on medication containers or packages; 71(a)
  2. Routine Inspection

    0 infractions

  3. Substantiated complaint

    1 infraction

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The system to ensure that policies are implemented by employees is ineffective. The facility's Safe Suctioning Policy and Procedure was not implemented by employees as evidenced by the nurse on duty being unable to locate the suction catheter in the person in care's room or in the Main North medication room. The policy directs that "suction equipment must be appropriate (correct catheter size and type); easily accessible, and must be checked regularly". The Licensee has provided a corrective action plan that meets legislative standards. This plan will be fully implemented by December 31, 2024, and will include ongoing monitoring and compliance audits by the Licensee.
  4. Routine Inspection

    1 infraction

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The system to ensure that policies are implemented by employees is ineffective. During a review of restraint monitoring documentation, it was observed that every two hour documentation was not completed as directed by facility policy and procedure.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  5. Routine Inspection

    4 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): Restraint monitoring records were incomplete, predominantly during the nighttime hours. This is a repeat contravention from the previous inspection.
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Diet preference sheets had not been updated to reflect the current nutrition care plan. Diet requisition sheets were stuck on top of the sheet providing current information. A diet requisition sheet was not evident (later found by staff) nor was the diet preference information for two new admissions available in one cottage.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.6 - Are facility records current and complete?
      • Observation(s): The facility has not conducted food satisfaction surveys with PICs and it was noted that this had been incomplete since the onset of the COVID 19 pandemic.
      • R4.6D - Retain the results of monitoring of food services and nutrition care; 87(c)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): A review of common areas and some PIC rooms indicated that there was gouged and damaged drywall, doorframes and doors, as well as repaired and spackled areas that had not been painted. This was noted throughout the facility and is a repeat contravention from the previous inspection. Facility leadership stated that these issues had been noted during a facility physical facility audit in the spring.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  6. Routine Inspection

    4 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): Licensing reviewed restraint monitoring documentation and noted documentation, predominantly when persons in care are not in the restraint, to be completed inconsistently. There is a system in place to audit and Leadership identified documentation as an area which remains in progress. This is a re-occurring contravention from the last inspection.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): On inspection of the physical facility it was noted the most recent inspection report and manager's name were not posted in a prominent location.
      • R1.1N - Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing observed inconsistent monitoring of refrigeration 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): On physical inspection of the facility, Licensing noted the following in cottage two: -The walls showing need of repair. -A section of the flooring had been cut out and taped down temporarily until a sink is to be installed. The taped section had lifted creating a tripping hazard.
      • 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)
  7. Substantiated complaint

    2 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Licensing was notified a person in care was involved in a reportable incident upon receipt of this complaint however, did not receive a report from the Licensee. This issue of non-compliance is secondary to the complaint and has been resolved.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The complainant expressed concerns a staff forcibly and aggressively removed a person in care, in a wheelchair, from the dining room and was pushed down the hall at a rapid pace. The staff yelled at the person in care from across the room and continued to yell down the hall. The Licensee conducted an internal investigation substantiating the complaint. A health & safety plan was in place during the investigation.
      • R10.2D - Ensure persons in care are not subjected to financial, emotional, physical, sexual abuse or neglect; 52( 1 )(a)
  8. Routine Inspection

    5 infractions

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): There are systems in place for monitoring of medication and treatment administration, monitoring of care and providing continued education to staff, as needed, to ensure persons in care needs are met in a manner consistent with the health, safety & dignity of persons in care. Due to staff levels, the staff responsible for this are unable to complete the tasks as they are working on the floor. An approved health & safety plan is in place to address the staffing concerns. To address this contravention, please submit a plan indicating how monitoring and education will be addressed.
      • R3.2A - There must be sufficient numbers of trained and experienced employees on duty at all times. Staffing patterns must meet the needs of persons in care and assist persons in care with activities of daily living, including eating, mobility, dressing, grooming and hygiene in a manner consistent with the health, safety and dignity of persons in care; 42( 1 )(a)(b) (Show More)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): Licensing reviewed restraint documentation. Documentation is not always completed. It appears some night shift staff do not document throughout their shift.
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): -Policy for monitoring post fall neurovitals is not accurately followed by employees. -Wound treatment plans have not been revised within the schedule as per 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): -Facility policy to complete performance evaluations within 6 months of employment have not all been completed within this timeframe. Facility policy is to complete performance evaluations every 2 years. Hospitality staff evaluations are up to date. Other departments are behind with completion.
      • 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)
    • 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): Upon Licensing's review it was observed restraint monitoring is not completed within the schedule ordered. The facility educator advised Licensing further education has been provided to staff and monitoring has improved however, restraint monitoring remains inconsistent.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  9. Routine Inspection

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The facility is currently following up on two incidents that were not reported to Licensing immediately, Licensing was aware of both incidents prior to this inspection. Please follow-up with Licensing upon completion of these matters. Inform Licensing on how reportable incident policies will be updated to ensure timely reporting.
      • 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): The facility recreation calendar of events currently does not include any evening or weekend activities. Inform Licensing on how the current calendar of events is meeting the needs of all PIC's.
      • 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)
    • RB1.23 - 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): Some PIC's are able to leave the building independently, ensure their care plans detail the specifics of this process (how long are they able to leave? what do staff do if they do not return by the specified time? etc...).
      • 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): Facility policy indicates performance evaluations for new staff are expected to be completed within 6 months of start date, some of these reviews are behind schedule.
      • 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)
    • 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): Some PIC's are able to leave the building independently, ensure their care plans detail the specifics of this process (how long are they able to leave? what do staff do if they do not return by the specified time? 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)
  10. Monitoring

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system in place for monitoring medication records is ineffective. A sampling of charts were reviewed and several missed signatures were noted on regular prescribed treatment creams on one record of a person in care. One treatment cream was time specific and had several missed signatures over the course of the prescribed 2 week period.
      • 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): Equipment is being stored in several of the tub rooms in the cottages. The tubs can not be accessed by persons in care due to equipment storage as well as tubs not being compatible for use by persons in care.
      • R7.2M - Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
    • 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): As previously noted in the inspection report: Equipment is being stored in several of the tub rooms in the cottages. The tubs can not be accessed by persons in care due to equipment storage as well as tubs not being compatible for use by persons in care.
      • 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): The system in place for monitoring the physical facility is ineffective. Debris and a turned up mat was noted in the outside area of one of the cottages. An oxygen tank was noted in the bathroom of a person in care and is accessible to persons in care who may wander into the room.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • 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)
  11. Monitoring

    1 infraction

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The system in place for ensuring the documentation of the effectiveness of PRN medication is ineffective. It was noted that the effectiveness of the PRN medication was not documented on several PRN medications. This missed documentation was noted in several cottages.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  12. Monitoring

    6 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): It was noted on the Medication Administration Record that a person in care was regularly self administering medications. There was no care plan in place for self administration of medication and no approval was given by the medication safety and advisory committee or the medical or nurse practitioner for the self administering of the medication.
      • Keep records of compliance with section 70 (administration of medication); 89( 2 )(d)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): It was noted during the inspection that restraint monitoring was not being captured or documented in the electronic record of a person in care. Although this was corrected during the inspection, there needs to be follow up to ensure all persons in care who use restraints are being monitored throughout the use of the restraint.
      • 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)
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): As previously noted in the inspection report: The door where person in care records are being stored was unlocked and accessible to anyone walking by. The staff member on duty stated that the door is to be locked and closed and locked the door during the inspection. This item was corrected during the inspection.
      • 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): The facility does not have a monitoring plan in place to ensure the monitoring of the persons in care safety and physical and emotional dignity is being completed throughout the use of the restraint.
      • 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): The door where person in care records are being stored was unlocked and accessible to anyone walking by. The staff member on duty stated that the door is to be locked and closed and locked the door during the inspection. This item was corrected during the inspection.
      • 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
    • 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): It was noted during the inspection that two person in care records with purple dots indicating behaviour care plans were incomplete. The care plans did not address what kind of behaviours were of concern and were not complete for triggers or interventions.
      • Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
  13. Monitoring

    7 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Several missed signatures were noted on the Medication Administration Record for regularly scheduled medications in several of the cottages. This remains outstanding from the previous inspection. A discussion took place with the Associate Care Coordinator in regards of the auditing system being used to monitor these records. Weekly audits are in place and this infraction will be followed up on.
      • 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): A sampling of person in care records were reviewed and two records were missing tuberculosis screens.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): As noted previously in the inspection report - an electrical appliance was found to be plugged in and partially blocking access to a persons in care room posing a safety risk and a potential tripping hazard. This item was noted on the previous inspection report. The appliance was moved and the Associate Care Coordinator had a discussion with the staff in regards to placement of the appliance in the persons in care room, securing the electrical cord and other safety options associated with the appliance being used. This was corrected during the inspection.
      • Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): A sampling of person in care records were reviewed and one record did not have information by which the person may be described in an emergency.
      • Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The door to the housekeeping room was found to be unlocked in one of the cottages. Cleaning supplies were accessible to persons in care. The door was locked by a staff member during the inspection. This infraction was corrected during the inspection. A pouch pack of medication was found on a chair in one of the cottages where the person in care charts are located. The pouch pack was in reach and accessible to persons in care. A staff member removed the pouch pack and was to properly dispose the medications. This infraction was corrected during the inspection.
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
      • Ensure all medications are safely and securely stored; 69( 3 )(a)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): A medicated prescription cream dispensed from another pharmacy was found in a persons in care bathroom. This item was noted on the previous inspection report. The cream was removed by a staff member and corrected during the inspection.
      • Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
    • 10.1 Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): An electrical appliance was found to be plugged in and partially blocking access to a persons in care room posing a safety risk and a potential tripping hazard. This item was noted on the previous inspection report. The appliance was moved and the Associate Care Coordinator had a discussion with the staff in regards to placement of the appliance in the persons in care room, securing the electrical cord and other safety options associated with the appliance being used. This was corrected during the inspection.
  14. Monitoring

    12 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Unable to locate the agreement from the medical practitioner on a restraint being used on a person in care.
      • 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)
    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Several missed signatures were noted on the Medication Administration Record for regularly scheduled medications in several of the cottages.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): There was no record of the duration or the monitoring of a restraint in the person in care records of a restraint being used. A signed risk agreement was on record.
      • 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)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): The care plan did not indicate monitoring frequency of a restraint being used on a person in care.
      • 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)
    • 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): As previously noted in the inspection report - an electrical appliance was plugged in and partially blocking access to a persons in cares room. Discussion with staff and maintenance man to finding alternative measures for this situation.
      • 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): As previously noted in the inspection report, a Medication Administration Record was left unattended in one of the cottages during the inspection. A staff member secured the Medication Administration Record in the medication cart during the inspection. Corrected during the inspection.
      • Respect personal privacy and keep records and personal information confidential.
    • 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): The effectiveness of PRN medication noted to be missing from the Medication Administration Record in several of the cottages. This remains outstanding from the past inspection report.
      • 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): Expired first aid certification noted on three staff members who require first aid.
      • Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): A Medication Administration Record was found unattended on top of the medication cart in one of the cottages. A staff member locked the Medication Administration Record in the medication cart during the inspection. Corrected during the inspection.
      • 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): Trim noted to be coming off of the wall in a persons in cares bathroom. Toilet cover missing off of a toilet in one of the tub rooms. (this was noted on last inspection report in same tub room) This item remains outstanding. Noisy bathroom fan noted in a persons in care bathroom. Several soiled areas noted to the hallway carpet in the main building. Laundry room door was propped open in one of the cottages. The door was closed by a staff member and corrected during the inspection.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Ensure that laundry facilities if not used by persons in care, cannot be accessed by persons in care; 35( 2 )(b)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): Over the counter medication and eye drops were found in the bathroom cabinet of a persons in care bathroom. This item remains outstanding.
      • Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
    • 10.1 Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): An electrical appliance was found to be plugged in and partially blocking the entrance of a persons in cares room. A discussion took place with the staff and maintenance man during the inspection and the staff are to seek alternative measures to address the situation.
      • Promote the health, safety and dignity of persons in care; CCALA 7( 1 )(b)(i)
  15. Monitoring

    6 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): The effectiveness of PRN medication was not always documented on the person in cares Medication Administration Record. According to the Medication policy, all PRN effectiveness is to be documented on the Medication Administration Record. The documenting of PRNs was noted to be missing throughout the facility/cottages.
      • 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): This remains outstanding from the past inspection dated October 2014 and an extension to complete has been approved by Licensing. The Health Care Aide evaluations have been started and are in the progress of being completed. In reviewing the staff records, one LPN was noted to be outstanding of an evaluation during the review of a sampling of staff records. The manager stated that there are approximately 200 staff employed at the facility and that all of the hospitality and leadership team evaluations have been completed.
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40(1)(a)(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Information by which a person in care may be described or identified in a emergency is not included in the documentation for persons in care. This remains outstanding from the past inspection report. There was documentation from "Corporate" in regards to changing the computer program to capture this information during the admission process. Although there is a process in the works in regards to this information being captured on the computer program, it does not resolve nor come in compliance with the Regulation. Time period to complete this follow up is one month from the date of the inspection. It was discussed during the inspection that this information could be hand written on the persons in care photograph sheet being kept on record. A progress note for a specific person in care was posted on the closet door in a cottage dining room. This same cottage had the resident "to do' list left on the counter accessible to passers by. Both of these documents contained personal information on persons in care.
      • Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78(1)(d)
      • 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
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Fridge temperature logs for the fridge located in the Recreation Room main building had several missed notations during the month of April. This remains outstanding from the past inspection report of October 2014.
      • 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): Toilet tank covers were missing in two bathing rooms. One of the bathing rooms is not in use but is used by the hairdresser. (These are different bathing rooms than noted on the previous inspection report of October 2014) Flooring was noted to be lifting in two person in care rooms during the inspection. One bedroom in cottage 4 and another bedroom in cottage 5. Several of the lifted areas were noted to be repaired in cottage 4 and improvement was noted since last inspection. Outside access areas to two cottages were noted to have garden hoses lying on the ground posing a safety risk to persons in care. Several outside BBQ's had gas tanks attached to the BBQ. This was noted during the last inspection. The tanks were removed for winter storage but now gas tanks are being installed for the upcoming BBQ season. There is to be a safety protocol in place to ensure safety for persons in care but no protocol was available during the inspection. Snack menu is listed separately on each posted menu plan. Several dining rooms did not have complete weekly snack menu plan posted and was missing any where from 1 - 3 weeks of the snack menu. A prescription treatment cream was found on the bathroom counter of a person in care.
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
      • Maintain all rooms and common areas in a safe and clean condition; 22(1)(c)
      • Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 (4)
      • Ensure all medications are safely and securely stored; 69(3)(a)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): An over the counter itch cream was found in the bathroom of a person in care.
      • Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69(1)(a)(b)