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Joseph Creek Care Village

1701 Willowbrook Dr N Cranbrook BC V1C 0A5 · Residential Care - Licensing

26 inspections

  1. Routine Inspection

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): R4.5G - A review of the non‑reportable incident reports and the licensee’s complaints log identifies that multiple reportable incidents have not been reported to Licensing as required. During the inspection, education was provided to the licensee on the specific Schedule D definitions related to the missed incidents. Failure to report incidents as required may result in delayed oversight and monitoring by Licensing, which could place persons in care at risk if concerns are not addressed in a timely manner. Submit by February 16, 2026, a written plan outlining how the contravention related to ensuring Licensing is immediately notified in the form and manner required of all reportable incidents has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 77(2)(c) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R4.5G - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): R4.1V - Multiple boxes containing historical incident reports and personal information of persons in care were found in an unlocked boardroom accessible to persons in care, staff, and visitors at the time of inspection. Upon identifying this infraction, the records were removed and secured in appropriate storage. Failure to maintain secure and confidential storage of personal and health information poses a significant risk to persons in care in a long‑term care setting. Unauthorized access to these records may compromise residents’ privacy and dignity and could result in the disclosure of sensitive health, behavioral, or personal details. Submit by February 16, 2026, a written plan outlining how the contravention related to ensuring confidentiality of records and personal information of persons in care has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 93 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R4.1V - 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
    • 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 - A review of care plans identified that one care plan does not include sufficient guidance for staff regarding the person in care's individualized behavioural needs. Specifically, the care plan does not clearly outline: the behaviours exhibited, the known or suspected triggers for the behaviours, and the strategies or interventions staff are expected to use to manage and support the person in care when the behaviours occur. Another care plan lacks clear direction related to the person in care’s abilities and the use of an as‑needed restraint. Although the person in care’s records contain current, ongoing monitoring of specific behaviours through a behaviour‑tracking system, the corresponding care plan did not clearly outline how staff are to support the person in care in a manner that ensures their abilities are respected while also maintaining their health, safety, and dignity. Without clear guidance in care plans, there is a risk that staff may not provide care in alignment with the person in care's preferences, which may impact their health, safety and dignity. Submit by February 16, 2026, a written plan outlining how the contravention related to ensuring care plans take into account the unique preferences of persons in care 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. R10.3M - A review of care plans and related documentation—including ongoing monitoring tasks signed in the Point Click Care system and behavioural tracking records—does not show evidence that the care and supervision provided to some persons in care consistently followed the requirements outlined in their care plans. When care and supervision do not consistently follow the requirements outlined in care plans, persons in care may be placed at risk of unmet health needs, unmanaged behaviours, increased likelihood of injury, deterioration in physical or cognitive status, and reduced overall quality of care. Submit by February 16, 2026, a written plan outlining how the contravention related to ensuring the care and supervision of persons in care is consistent with the care plan, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 82 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)
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  2. Routine Inspection

    2 infractions

    • 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 at least 2 nutritious snacks with at least 2 food groups is provided daily is ineffective. During the inspection it was identified that the afternoon snack provided did not contain 2 food groups, and did not match the snack documented on the daily menu.
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • R10.3 - 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 care plans for persons in care at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care is ineffective. It was identified during the inspection that not all care plans for persons identified at risk of leaving the facility included a plan to locate the person in care. The system to ensure the care and supervision of persons in care is consistent with the terms and conditions of the person's care plan is ineffective. It was identified during the inspection that documentation outlined within a care plan was not completed at the intervals as specified in the care plan. The documentation contained multiple days with large spans of time that were incomplete.
      • R10.3G - Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
      • R10.3M - 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
  3. Routine Inspection

    4 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 policies are implemented by employees is ineffective. During the inspection it was identified that required assessments, as well as reassessments were not completed as per policies. The identified assessments included smoking assessments, as well as quarterly assessments.
      • 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): The system for ensuring all required staff have valid first aid is ineffective. During a review of employee tracking records, it was identified that multiple employees required to hold a valid first aid certificate did not meet the requirements.
      • R3.1R - 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system to ensure the health and safety of persons in care is monitored regularly to determine if their needs continue to be met is ineffective. It was identified during the inspection that a 'smoking assessment' had not been completed on a person in care who regularly smokes.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The system to ensure each care plan is monitored on a regular basis to ensure proper implementation is ineffective. During a random chart audit it was identified that a person in care's care plan listed two differing restraint types. The discontinued restraint had not been removed from the current care plan with the addition of the current restraint.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  4. 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): The system to ensure that policies are implemented by employees is ineffective. Policies "PCS 101" and "PCS 105" were not implemented by employees as evidenced by housekeeping services not taking place in the Jim Smith unit on March 16 and 17, 2024.
      • 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. Housekeeping services did not take place, or follow enhanced preventative measures during the declared outbreak, in the Jim Smith unit on March 16 and 17, 2024.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
  5. Routine Inspection Follow-up

    0 infractions

  6. Routine Inspection

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing acknowledges efforts to increase self-monitoring of the care and services provided as as evidenced by the increase in completed audits. However, the system in place for ensuring ongoing compliance is ineffective as evidenced by the number of new, and re-occurring contraventions identified within this report. This is an ongoing contravention from the November 2022, and May 2023 inspections, and re-occurring from the February 2021, June 2022, November 2022 and May 2023 inspections.
      • 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): During the May 2023 inspection the Licensee self identified non-compliance with employee performance appraisals. However, there is no documented evidence that a system of plan was implemented at that time, and non-compliance continues. This is a re-occurring contravention from the June 2020, September 2020, and January 2021 inspections.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It was identified during the inspection that the licensee does not currently have a system in place to ensure persons in care who may leave the facility without notifying an employee are fitted with identification indicating the person's name, facility, and emergency contact information. Multiple persons in care were identified as being at risk for elopement, with no evidence of identification as required by the legislation. This is a re-occurring contravention from the January 2021 inspection.
      • 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): The system to ensure care plans include a plan to address behavioral interventions is ineffective. A care plan referenced a behavioral care plan, however, there was no evidence of any behavioral interventions outlined in the care plan. This is a re-occurring contravention from the January 2021 inspection. The system to ensure that care plans are reviewed and modified ensuring it meets the person in care's needs and preferences and is accurate is ineffective. The review dates were noted to be current within the past year, however, multiple care plans were noted to contain past information that was identified as no longer being accurate.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  7. Routine Inspection

    4 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The system to ensure restraint monitoring is completed is ineffective. During a review of person in care's charts it was noted that restraint monitoring documentation was inconsistently completed, and some records were noted to be documented prior to being monitored.
      • 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): Licensing acknowledges efforts to increase self-monitoring of the care and services provided as as evidenced by the increase in completed audits. However, monitoring to ensure compliance is ineffective as evidenced by the lack of corrective actions identified within the audits. This is an ongoing contravention from the November 2022 inspection.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The system to ensure policies are implemented by employees is ineffective. Through random chart audits, and review of documentation on site, it was noted that policies related to the following areas were not being implemented: 1) Restraint Monitoring 2) Documentation This is an ongoing contravention from the November 2022 inspection.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The licensee does not currently have a system in place to ensure persons in care who leave the facility independently have a plan in place. The Licensee's system to ensure that wound care plans are being followed was found to be ineffective. During the inspection it was observed that wound care treatment was not being provided as per the frequency written in the wound care plan.
      • 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)
      • R10.3M - 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
  8. Routine Inspection

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Night shift duties posted in the Nursing station had no system in place to ensure implementation. First Rounds Reference Check list was dated 13 July with person(s) in care still on the list that no longer reside in the facility. During this inspection it was noted that the water temperature recorded in a tub room was inconsistent. There was no record of temperature recordings in the shower room.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): In reviewing persons in care records, it was noted that the policy of reviewing every 90 days was ineffective. Dietary information sheet was last updated June 2002.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It was noted that there was an Occupational Therapist referral to assess for a diet change, there was no evidence of completion. The system to ensure the health and safety was not monitored to meet the needs of the person in care. It was noted in the care conference notes that Occupational/Physical Therapist were to assess a transfer pole with no evidence that this was completed. The auditing system to review the care plan to ensure implementation was ineffective.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Licensing noted that a Wandering Support Plan no longer met the terms and conditions of the persons care plan as their Mental Health Certificate had expired. The auditing system to review and modify the care plan was ineffective.
      • 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. Routine Inspection

    3 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Of the charts and audits reviewed, it was identified that the system to ensure reassessments, and restraint consents are reviewed and completed was ineffective.
      • R10.4N - Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The systems in place to regularly monitor the physical environment and the care and services provided to persons in care are ineffective. This was evidenced by the following monitoring systems being ineffective: 1. Medication room fridge temperatures were inconsistently recorded 2. Currently no system in place to monitor as needed medication administration and documentation of effects 3. No monitoring system in place to monitor or guide the reassessment of medication self administration care plans 4. Monitoring of the implementation of health and safety plans.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • 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 care plans include a plan for persons in care who leave the facility independently was ineffective. Of the charts reviewed, it was noted that only one person in care who leaves the facility independently, had a plan and process in place.
      • 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. Routine Inspection

    4 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The system for ensuring that all persons in care have a falls care plan in place appeared to be ineffective. Licensing officers noted that despite all persons in care being assessed for the risk of falls, if any person in care was noted to be a low risk, there was no indication of what the universal fall precautions were to be in place.
      • R10.4P - Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (Show More)
    • 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): This section of legislation was noted to be out of compliance during a recent complaint investigation. The licensee submitted a plan on October 25th which was accepted by licensing. The target completion date for correction has not yet been reached.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system for ensuring persons in care are weighed monthly appeared to be ineffective. Of the records reviewed, the licensing officers noted numerous persons in care did not have a weight recorded for some of the months since the last inspection.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The licensee has noted some mechanical issues in need of repairs. As a result, some ceiling tiles have had to be removed temporarily. In one area, the mechanical issue has caused a small leak which is being addressed, however, in the interim, a bucket was noted to be on the floor which licensing officers identified as a risk. This item was corrected during the inspection as the area was closed off from persons in care.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
  11. Substantiated complaint

    1 infraction

    • 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): Allegation - the licensee is non-compliance with section 81(4)(a). Allegation - the licensee is non-compliance with section 81(4)(b). Investigation findings - in review of records and discussions with the licensee, licensing confirmed that that a specific intervention listed in a care plan was not being implemented for a short period of time. The allegation of non-compliance with section 81(4)(a) is SUBSTANTIATED. Investigation findings - in review of records and discussions with the licensee, licensing confirmed that a change in status to a person in care was not reflected in the person in care's care plan and therefore; the allegation of non-compliance with section 81(4)(b) is SUBSTANTIATED.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
      • 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)
  12. 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): Contravention arising from the investigation: The Licensee has a system in place to ensure that persons in care are assessed for aggressive behaviours. Although ongoing assessment may have been conducted the Licensee was unable to provide documentation of ongoing assessment as per the Purple Dot policies and procedures.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Allegation - the Licensee is in non-compliance with Residential Care Regulation Section 81(4)(b). Investigation findings - The two care plans reviewed by Licensing were noted to not contain certain needs and/or preferences for the persons in care therefore; the allegation of non-compliance with Section 81(4)(b) is SUBSTANTIATED.
  13. 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): August 22, 2021 Allegation - The Licensee is in non-compliance with RCR 85(1)(d), ensuring that a facility policy is implemented by all staff. Action - The allegation was investigated by Licensing with the Licensee. It was determined that one staff member did not follow a policy therefore; the allegation of non-compliance with RCR 85(1)(d) is SUBSTANTIATED.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  14. Substantiated complaint

    1 infraction

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The complainant expressed concerns to licensing that the licensee did not report an incident to licensing. Licensing officer reviewed the facility records and noted an incident which was reportable to licensing had not been submitted as required. The licensee took immediate action and the response was accepted by licensing.
      • 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)
  15. Substantiated complaint

    1 infraction

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): The complainant alleged that there were issues with staffing on the dates of July 17 and 18, 2021. Licensing officer reviewed documentation which indicated that there were issues with care provision on these dates. Licensing finds this complaint substantiated. At the time this report is being written, a plan to address this contravention has been received and accepted by licensing.
      • 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)
  16. Routine Inspection

    1 infraction

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system in place to ensure that all medications ordered are administered to persons in care appeared ineffective. On a random audit, licensing officers noted a person in care did not have a medication administered as ordered. The system in place to ensure that all treatments which are prescribed are documented as given appeared ineffective. Upon a random audit of records, licensing officers were unable to confirm that treatments had been given as ordered.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
  17. Routine Inspection

    9 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): The system for ensuring that the required consents are in place for restraint use appeared ineffective. The director of care had a folder of consents completed in the office, in addition, verbal consent had been obtained and documented in progress notes. Evidence was in place indicating that contacts had been given restraint information, however, consent had not been completed for a few persons in care.
      • R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system for ensuring all incidents are reported to licensing as required was noted to be ineffective. Licensing reviewed person in care records and noted an incident which had not been reported. This is an outstanding contravention and was noted out of compliance on the last inspection dated September 23, 2020. A plan is currently in place to address this contravention.
      • 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)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The system to ensure that falls interventions are indicated in care plans appeared ineffective. Licensing noted that a fall assessment indicated what interventions were to be in place, however they were not included in the person in care's care plan. The interventions were noted to be in place at the bedside.
      • R10.4P - Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (Show More)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The systems in place to regularly monitor the physical environment and the care and services provided to persons in care appears to be insufficient as evidenced by the non-compliance outlined in this report. In a random audit, licensing noted a person in care had a fridge in their room. A care plan was in place in regards to the fridge. However, there was no evidence relating to the monitoring of the fridge. Self-monitoring is an outstanding contravention from September 23, 2020.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • RB1.25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): See R 10.3 above for details. Care plans are not developed as per requirements in Section 81 of the Residential Care Regulation.
    • 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 for ensuring policies are implemented by employees was noted to be ineffective December 9, 2020. The licensee is currently implementing their corrective action to address this with a target completion date of February 28, 2021.
      • 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): The licensee continues to work through the performance reviews for all staff. Progress has been made with their system for conducting performance reviews. The licensee's target date for the completion of all staff to have their review conducted is March 31, 2021.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system for ensuring that persons in care who are required to have ID in place appeared ineffective. In review of person in care records, licensing noted that a person in care at risk for elopement did not have ID 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): The system for ensuring that care plans are in place for persons in care was noted to be ineffective. Licensing noted a person in care with history of wandering and exit seeking did not have an elopement care plan in place. Licensing noted care plans indentified persons in care having behaviours. However, some were not individualized interventions to guide staff in supporting persons in care and some did not have interventions at all. The flagging system for identifying persons in care at risk of elopement or aggression appeared ineffective. A care plan for a person in care indicated that safety checks were required every two hours. There was no evidence that these safety checks were occurring. A monitoring system was implemented. This was corrected during the inspection
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3G - Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
      • R10.3M - 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
  18. Routine Inspection

    6 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system in place to ensure all incidents are reported to licensing as required appeared ineffective. Upon a review of all reportable and non-reportable incidents since 12-June-2020, one incident had been flagged by the licensee as needing to be reported to licensing, however, the incident report was never received by licensing. The is an outstanding infraction noted to be out of compliance 03-Mar-2020, and 12-Jun-2020.
      • 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)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The system used to identify person in care immunization status was noted on 12-June-2020 to be ineffective. The compliance plan accepted by licensing on 10-July-2020 indicated the target completion date of 3 months. Licensing confirmed that the process is well underway at this time.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The systems in place to regularly monitor the physical environment and the care and services provided to persons in care appears to be insufficient. Although improvements were noted since the inspection dated 12-June-2020, there are still areas of repeated non-compliance noted below under the applicable sections of legislation. This is an outstanding contravention.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The inspection dated 12-June-2020, identified numerous polices were not being followed. The target completion date for this contravention has not yet been reached. At the time of this inspection numerous policies remain under review as per the compliance plan accepted by licensing 10-July-2020. Licensing confirmed staff education has been occurring.
      • 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)
      • 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): The inspection on 10-June-2020, identified that numerous staff files were missing CRC requirement. Since that inspection, all staff who were missing this requirement have applied for CRC and licensing confirmed at this inspection that the submitted Health and Safety plan is being followed. The system in place for ensuring performance reviews are conducted regularly appeared to be ineffective. This was noted on the inspection from 10-June-2020. At the time of this inspection, the target completion date for this contravention had not yet been reached. Licensing confirmed measures are in place to review performance of staff as issues arise. The food service Manager does not hold a membership in the Canadian Society of Nutrition Management (CSNM). This was CORRECTED DURING INSPECTION. Fire drills were conducted in July, however there is no evidence of staff training in emergency plans and the use of applicable equipment since that time. This is an outstanding contravention previously found out of compliance on 31-Jul-2018 and 12-June-2020.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • 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)
      • R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
    • R10.3 - 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 staff provide care as per the directives in a care plan appeared ineffective. Upon a random audit, one care plan indicated specific monitoring with documentation which was not occurring. An updated care plan and revision of monitoring system was implemented the date of the inspection.
      • 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
  19. Routine Inspection

    22 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): An emergency restraint was implemented in May 2020 and there was no evidence that this restraint was approved by written agreement by the medical or nurse practitioner. The monitoring of persons in care regarding restraints is inconsistent. Reassessments for the need of a restraint is not regularly occurring in cases where a restraint continues for more than 24 hours. Evidence of alternatives that have been considered or tried is not clear in the documentation. Upon review of documentation, Licensing observed that a person in care fell eight times in one month. A falls risk assessment was not completed nor was a plan created for preventing subsequent falls.
      • R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
      • R2.2B - Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73( 2 ); 75( 2 )(a)(i)(ii)(b)
      • R2.2C - Written falls prevention policies and procedures are required for assessing risks that may result in a person in care falling including a plan for preventing falls, responding to falls suffered and including care and subsequent prevention(Applies only to Long Term Care); 85( 2 )(a)(i)(ii)(iii). (Show More)
    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): A person in care who self-administers medication has a medication administration record; however, this record does not demonstrate the date, amount, and time at which the medication was administered. The self-administration agreement does not provide evidence of how staff are monitoring the plan.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): Upon review of progress notes, it is unclear if a restraint was initiated for a person in care, and the nature or type of restraint potentially used, nor does the documentation indicate sufficient follow-up. Upon review of persons in care's charts, it was observed that restraint monitoring, ongoing reassessments and the results are inconsistently recorded. There was no evidence noted in persons in care's care plans to confirm employee compliance with RCR Division 5 (Use of Restraints) of Part 5.
      • R4.3A - Record the type or nature of the restraint used in the person's care plan; 84(a)
      • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
      • R4.3F - Keep a record of employee compliance with the requirements of Division 5 (Use of Restraints) of Part 5 in the persons care plan; 84 (f)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Notification to person in care's representative/contact person(s) is not indicated on both in house and incident reports reportable to Licensing. Incident reports do not indicate that the medical or nurse practitioner has been immediately notified. Licensing reviewed in house incident reports and identified incidents requiring submission to Licensing, however they were not received. These reportable incidents are considered high risk (falls, aggression between persons in care, aggressive or unusual behaviour and emergency restraint). The identified reportable incidents were not reported to the funding program as required. Residential Care Regulation (RCR) Section 77(2)(c) is an outstanding and ongoing contravention. The Licensee was originally found out of compliance on 21-Feb-2019 and on 03-Mar-2020. The Licensee's compliance plan is not being followed and this issue remains outstanding.
      • R4.5A - Immediately notify the parent, representative or contact person if a person in care becomes ill or injured while under the care or supervision of the licensee; 76 ( 1 )
      • R4.5B - Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77( 2 )(a)
      • R4.5C - Immediately notify the medical or nurse practitioner responsible for the person in care involved in a reportable incident; 77( 2 )(b)
      • 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)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Persons in care records do not comply with the Province’s immunization program. While the facility has a process to capture this information through an immunization questionnaire, this process is not being followed.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): There is no evidence that employees have been trained in the alternatives to the use of restraints or when to use restraints. Staff faxed a medical practitioner to request the use of a restraint in response to displayed behaviours. This type of implementation of a restraint is not appropriate as per the legislation. Licensing observed on two occasions the use of an emergency restraint where no follow-up was indicated. Restraint care plans are inadequate as they are missing required documentation. Assessing the need for the restraint at least once within 24 hours and in consultation with the persons who agreed to the restraint use, is not evident.
      • R10.4A - Ensure a restraint is not used unless necessary to protect the person in care or others from serious physical harm; 73 ( 1 )(a)
      • R10.4E - Train employees in alternatives to the use of restraints. They must be able to determine when alternatives are most appropriate, when to use restraints and how to monitor the use of them; 73( 2 )(b)(i)
      • R10.4K - Document in the care plan, the advice and information given following the use of an emergency restraint; 73( 3 )(b)
      • R10.4N - Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
    • 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): See comments previously noted in this inspection report
      • RB1.17A - Post the most recent routine inspection in a prominent place.
    • RB1.19 - Are rights of adult persons in care displayed in a form and in the manner acceptable to the minister?
      • Observation(s): See comments previously noted in this inspection report
      • RB1.19A - Display the rights of adult persons in care in a form and manner acceptable to the minister.
    • RB1.25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): See comments previously noted in this inspection report.
    • RB1.26 - Is a short term care plan developed on admission to guide staff in protecting and promoting the health and safety of the person in care?
      • Observation(s): See comments previously noted in this inspection report.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The systems in place to regularly monitor the physical environment and the care and services provided to persons in care are insufficient. This is evident by the numerous contraventions listed in this report. Outstanding and reoccurring contraventions are noted and are identified under the applicable legislation. The Manager’s name is posted on an office door which is located in the centre of the building near the chapel. This display is not a prominent location for the long-term care residence. The routine inspection posted is not the most recent routine inspection. The inspection posted is dated 31-Jul-2018. The most recent routine inspection is dated 21-Feb-2019. Golden Life Management's Bill of Rights is posted in the facility, however the BC Government's Bill of Rights is not posted as required. Residential Care Regulation (RCR) Section 61 is a reoccurring contravention originally found out of compliance on 31-Jul-2018.
      • 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)
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
      • R1.1Y - Display the rights of adult persons in care in a prominent place and in a form acceptable to the minister; Act 7( 1 )(c.1)(i)(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): Employees are not given direction in all matters related to care. The orientation checklist upon hire indicates that employees are oriented to the Community Care and Assisted Living Act (CCALA) and Residential Care Regulation (RCR) and this same checklist states that staff are oriented to facility policies. A total of twelve polices were observed as not being followed, therefore this indicates the orientation process and opportunities for ongoing education is insufficient. A specific breakdown of the observations is listed below. There appears to be no system in place to ensure employees implement the facility's policies and procedures, and employees are not monitored for implementation of the facility’s policies. Employees were noted to not be following the policies listed below. 1) There is no wound care policy to guide employees in would care treatment, documentation and referrals ie: OT/PT. Dietician, wound care nurse. Licensing observed that some persons in care received wound care treatment; however, the wound care sheets contained inconsistent documentation. 2) Incident reporting (in house and to Licensing) – this policy does not adequately guide employees to report incidents as required by the legislation. Education provided via email by Licensing in January 2020 to use the online portal for reportable incidents. 3) Care planning – this policy does not direct employees to update care plans with a change in a person’s condition or at least once per year. 4) Oral care – this policy is not being followed as there is no documented evidence that persons in care are offered dental services at least once a year, nor are dental assessments completed on admission to the facility. Additional contraventions associated with this issue are outlined later in this report. 5) Aggressive or unusual behaviour – assessments are not being completed as per facility policy. 6) Restraints – this policy does not sufficiently guide employees regarding emergency restraints. Additional related areas of non-compliance are noted later in this report. 7) Falls – falls assessments are not completed following each fall as per the facility's policy. Employees are not following the no lift policy; progress notes indicate that persons in care have been lifted manually off the floor and the mechanical lift was not used as directed. 8) Documentation – DARP (data, action, response, plan) is not being implemented as stated in the policy. Documentation is primarily capturing data only; there is no consistent or clear documentation regarding referrals, follow-up, or outcome. 9) Self-administration of medication – this policy is not being monitored for implementation by staff. Additional contraventions related to this issue are noted later in this report. 10) Admissions – this policy is not being implemented. Additional contraventions related to this issue are noted later in this report. 11) Performance review – it was observed that this policy is not being followed, as performance reviews are not being completed as per the timeline stated in the policy. 12) Inspection for maintenance and fire protection – this policy is not being followed. Additional contraventions related to this issue are identified later in this report. 13) Occupational and Physical Therapy – the policy states that the Director of Clinical Care is responsible for reviewing persons in care's progress notes with respect to referrals and follow-up; however there is no evidence that this is taking place. Residential Care Regulation (RCR) Section 85(1)(d) is a reoccurring contravention previously found out of compliance on 11-Sep-2018. RCR 85(1)(a) was originally found out of compliance on 19-Jun-2019 and 26-Jul-2019. In these instances the compliance plans are not being followed and these issues remain outstanding.
      • 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)
      • 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): The process to ensure that all employees have a valid criminal record check (CRC) is ineffective. The facility has implemented a tracking sheet however, the information on this sheet has not been cross referenced or verified with employee files. The manager confirmed the spreadsheet is not up to date. Licensing observed staff files missing the CRC requirement. A health and safety plan (H&SP) was requested by Licensing regarding the Licensee's plan to ensure that all employed persons have a completed CRC. The plan has been received and approved by Licensing. Staff files are missing character references. Staff files were noted to not consistently contain a record work history. Employees identified as requiring first aid and CPR certificates do not consistently contain up to date certificates in their files. A health and safety plan (H&SP) was requested by Licensing regarding how persons in care will have immediate access to an employee at all times who holds a valid first aid and CPR certificate. The plan has been received and approved by Licensing. A kitchen staff file contained an expired food safe certificate. The food service Manager does not hold a membership in the Canadian Society of Nutrition Management (CSNM). A fire drill record from April 2020 stated that staff are not prepared for or trained in emergency preparedness. While the facility self-identified this issue, there is no specific plan of action currently in place. The Manager reported that they are creating a plan to provide support and education to staff. Residential Care Regulation (RCR) 51(3) is a reoccurring contravention previously found out of compliance on 31-Jul-2018. RCR Sections 37(1)(a) and RCR 37(2)(b) were originally found out of compliance on 03-Mar-2020. The Licensee's compliance plans are not being followed and these issues remain outstanding.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • R3.1C - Obtain character references for all employed persons; 37( 1 )(b)
      • R3.1D - Obtain a record of work history for all employed persons; 37( 1 )(c)
      • R3.1Q - Ensure employees responsible for the preparation and delivery of food have the necessary experience, competence and training to ensure that food is safely prepared and handled, and meets the nutrition needs of persons in care; 44 ( 1 )(a)
      • 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)
      • R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The procedure to ensure a short-term care plan is developed on admission is ineffective. A person originally received into care as respite and later admitted to the facility does not have sufficient information in their care plan to guide staff regarding behaviour interventions for responsive behaviours and the identified elopement risk as outlined by the referral source. Licensing observed that short term care plans are inconsistently developed and missing required information as per the legislation.
      • R4.1O - Ensure a short term care plan is developed on admission that guides caregivers in protecting and promoting the health and safety of the person in care; 80 ( 1 )
      • R4.1P - Ensure a short term care plan developed on admission includes anything that must be recorded in a care plan; 80 ( 2 )
      • R4.1Q - Ensure a care plan is developed within 30 days for persons in care admitted for more than 30 days; 81.1; Director of Licensing Standards of Practice: Advance Directives and Care Plans
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): Please see previous comments and information above in Staffing section R3.1.
    • R4.6 - Are facility records current and complete?
      • Observation(s): There is no system in place at this time to record menu substitutions. Education was provided by Licensing to staff during the inspection. There is no evidence of the monitoring of food services and nutrition care at this time. Education was provided by Licensing to staff during the inspection.
      • R4.6C - Retain food services records of menus and menu substitutions; 87(b)
      • R4.6D - Retain the results of monitoring of food services and nutrition care; 87(c)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Kitchen staff communicated that at times substitutions to the menu occur. However, there is no evidence of when or why substitutions occurred or the items that were substituted. Currently there is no system in place to verify that food is prepared and served with consideration of the preferences and cultural background of the persons in care.
      • R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
      • R5.1K - Ensure that food is prepared and served in a manner that, to the extent practicable, is consistent with the personal preferences and cultural background of the persons in care; 63 ( 2 )
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Upon the physical inspection, a tub room was noted to contain unlabelled personal care items (ie: hair brush, comb). The facility has a practice where personal items used in the tub room are stored in a labelled basket. This process appears to be inconsistently applied. This issue was corrected during the inspection and management provided education to staff present on this topic. There is no evidence that the temperature is being monitored for a fridge located in the room of a person in care to ensure food is safely stored. Licensing further observed unlabeled food with no expiration date in this fridge.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Upon review of the documentation for the cleaning of the tub it was observed to be inconsistently recorded. The facility tracking sheet did not consistently contain signed initials dates/times to indicate the tub was sanitized after each use. A bed is stored in a shared hallway around a corner. This location of storage is not visible until a person rounds the corner. The bed also blocks the handrail on the wall. This issue was corrected during inspection. The system to ensure that all rooms are maintained in a safe condition is ineffective. Topical wound treatments and wood furniture polish were accessible to persons in care. This issue was corrected during inspection and management provided staff present with education on this matter. Maintenance is not inspecting and monitoring the equipment specific to fire (i.e: fire alarm batteries, emergency exits and lighting, and the annunciator panel) as required. This activity is currently completed during an annual fire review by the local fire inspector. A person in care who is independently mobile has a falls mat placed beside their bed and in front of their washroom entrance during the daytime. The falls mat appears to pose as a tripping hazard. The recreation room is accessible to persons in care and was noted during the physical inspection to contain an unlocked cupboard storing bleach and other cleaning agents. A shared washroom located in a unit for persons in care was observed as having an aerosol spray deodorizer marked with poison symbols accessible. Unlabelled cleaning products observed accessible in an unlocked tub room. This issue was corrected during the inspection and staff present were provided education on this matter. However, during subsequent physical inspection of a different tub room, on a different day was observed to have unlabelled cleaning products accessible. A laundry room located near to the Jim Smith unit had a door propped open leaving it accessible to persons in care. This issue was corrected during the inspection by Licensing and education was provided to staff present on this matter. The staff locker room is accessible to persons in care, lockers were noted to be unlocked and contained items that could pose a risk to persons in care. Residential Care Regulation (RCR) Section 35(1)c) is a reoccurring contravention previously found out of compliance on 31-Jul-2018.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
      • 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)
      • R7.1AM - Ensure that laundry facilities if not used by persons in care, cannot be accessed by persons in care; 35( 2 )(b)
    • R10.1 - Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): There is no evidence that the “Care Organizer Pre-Admission Questionnaires” are being completed as per the facility's policy and procedure. The questionnaire is intended to assist with screening a person coming into care to ensure that the care they receive is both safe and adequate for their needs. Care planning for persons admitted for more than 30 days does not capture the information as required by the facility’s admission policy.
      • R10.1D - Screen the person before admission to ensure they will receive both safe and adequate care; 47 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There are no systems in place to monitor the health and safety and ensure each person in care's needs continue to be met. Examples are listed below: 1) There is no evidence for the monitoring of the staff contingency plan. The plan was updated in May 2020, however it does not provide guidance to employees in terms of assessing priorities in care delivery and there is no plan for the monitoring of the contingency plan to ensure its ongoing effectiveness and that care needs continue to be met. 2) The facility has a call bell system in place, however there is no process to monitor the system. Staff from one department provided information to Licensing regarding the process for capturing call bell response times. Licensing advised a leadership staff of where to find the information. The leadership staff was able to locate the information and confirmed that it currently is not being monitored to ensure that immediate assistance is provided to persons in care. 3) Charting does not indicate how persons in care have been encouraged to be examined by a dental health care professional at least once every year. While previously mentioned as insufficient implementation of the policy, a contravention is noted here with respect to there being no clear process to assist persons in care to obtain professional dental services as required. 4) Annual care conference planning notes were observed to be frequently left blank regarding the needs of a person in care specific to obtaining dental services. Care conference planning does not sufficiently address whether a person in care is independent or dependent as it pertains to dental services that may be required. 5) There is no process in place to ensure that persons in care who temporarily leave the facility carry facility identification including, name, facility name, emergency contact information. 6) There is no system in place to ensure that persons who may leave the facility without notifying an employee and may not be capable of identifying themselves are fitted with a means that would assist them to identify themselves.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • R10.2H - Encourage persons in care to be examined by a dental health care professional at least once every year; 54( 3 )(a)
      • R10.2J - Assist persons in care to obtain professional dental services as required; 54( 3 )(b)(ii)
      • 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 )
      • R10.2M - 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): Care plans are not updated when a person in care experiences a change in their condition. Persons in care who have been noted to have aggressive or unusual behaviour are missing a behavioural care plan with interventions to guide employees. The process to review and modify care plans to ensure the needs of each person in care continue to be met is inadequate. One person in care had eight falls in one month and there was no evidence of a falls care plan, assessment or other strategies to review the abilities of the person in care. Licensing observed minimal documented evidence regarding post falls measures implemented in order to prevent future falls. Assessments are not completed on indication of aggressive or unusual behaviour; therefore, appropriate care planning has not been activated. Care plans that do note aggressive or unusual behaviour do not consistently guide staff regarding triggers and interventions for the behaviours. Care plans for persons in care who experienced new or escalated responsive behaviours do not indicate further assessments. Residential Care Regulation (RCR) Section 81(3) (a)(ii) and Section 81(4)(a) are reoccurring and were previously found out of compliance on 31-Jul-2018.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
      • 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
  20. Routine Inspection

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system to ensure that immediate notification of a reportable incident occurs appears to be ineffective. A review of incident reports submitted since the last inspection indicates that many incident reports have not been received by the medical health officer in the timely manner required.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The facility does not have a system in place to ensure that height and weight is recorded for each person in care upon admission.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system for monitoring the health and safety of each person in care to determine whether their continuing needs are met appears to be ineffective. Licensing Officer observed that a person in care's record indicates daily application of respiratory equipment. There was no record of this application. The facility had an historical record with some instructions for use however there was no indication of review or any advice on possible discontinuation.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  21. Monitoring

    7 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing observed ongoing non-compliance in the physical environment, staffing, policies/procedures and care/supervision areas. Inform Licensing of the system and/or audit the facility will put in place to ensure that the requirements of the Act and regulation are being met.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The emergency plans are missing required information and does not set out how persons in care will continue to be cared for in the event of an emergency.
      • R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
      • R2.1G - Have a plan that sets out how persons in care will continue to be cared for in the event of an emergency; 51( 1 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Director of Community Care advised that the staff performance reviews are incomplete. The system in place for ensuring that each employee is trained in the implementation of the emergency plans described in subsection 1 (of Section 51 (1) is ineffective.
      • 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)
      • R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The persons in care menu posted in the dining area did not include 2 nutritious snacks. A licensee who provides Long Term Care must display in a prominent place in each dining area the menu for each weekly period (RCR 62 (4)).
      • 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 ensuring all hazardous items are safely and securely stored is ineffective. This was evident by observing the following: -Persons in care have access to the kitchen areas in each unit. These have sitting and brewing coffee makers, dishwashers (with temperatures observed from 77-83 degrees) and hot holding food dishes (required to maintain at least 60 degrees). Licensing observed 6 persons in care in the vicinity with no staff present for a significant period of time. Staff stated the current system of the movable/blocking band is ineffective as the persons in care are gaining access to the above hazards. -One unit had an unlocked drawer containing a sharp knife and another unit left several persons in care without supervision in this area. This was corrected during inspection (CDI). -Persons in care have access to several unlocked/unsecured rooms. This included rooms with paint, tools, renovation supplies, electrical panels, laundry and designated staff rooms. -Exposed electrical outlet, ladder, vacuum and garden hose were also accessible to persons in care during physical inspection of the facility. -Director of Care informed that each persons in care private washroom cabinet is to be locked. However, Licensing observed some cabinets unlocked.
      • 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)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Director of Community Care advised Licensing that the medication safety and advisory committee was overdue for an inspection/meeting.
      • R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(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): The process in place for identifying and developing a plan to address persons in care aggressive behaviour is ineffective. A random audit of a persons in care chart indicated no detail or specific information to address their behaviour. The aggressive person alert system (purple dot) was not up to date. Director of Community Care advised that one of the Nurses will be reviewing this.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  22. Monitoring

    4 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Upon review of one person's care plan, the Licensing Officer was unable to locate written agreement to the use of a restraint. The Manager provided Licensing with confirmation that this information was on file prior to the completion of the inspection report; therefore, considered corrected during inspection (CDI).
      • R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): Upon review of one person's care plan, the Licensing Officer was unable to locate the reason and plan for the use of a restraint. The Manager provided Licensing with confirmation that this information was on file prior to the completion of the inspection report; therefore, considered corrected during inspection (CDI).
      • R4.3B - Record the reason for the use of restraint in the person's care plan; 84(b)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Upon review of one person's care plan, the Licensing Officer was unable to locate information in addition to a photograph that could be used to identify them in case of emergency. The Manager provided Licensing with confirmation that this information was on file prior to the completion of the inspection report; therefore, considered corrected during inspection (CDI).
      • R4.1F - 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): At time of visit, one bathing room door was propped open. When the Licensing Officer notified the Manager or this observation, she immediately directed maintenance personnel to remove the door stops from all bathing room doors to prevent the doors from being propped open by staff. Licensing received written confirmation from Manager that this was done prior to the completion of the inspection report; therefore, this issue is considered corrected during inspection (CDI).
      • 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)
  23. Monitoring

    7 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Licensing has noted incomplete documentation on prescription creams prescribed to person's in care. There is an ineffective process in place to ensure that these records are audited to ensure that they are completed.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing has noted that the licensee has not given notification of a manager change.
      • R1.1E - Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Licensing has noted that the facility is not conducting performance appraisals annually for employees, which does not support the Golden Life policy to conduct annual performance appraisals on employees. This is an ongoing contravention since Dec 2014.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Licensing has noted irregular performance appraisals in employee records. This is an ongoing contravention since Dec 2014. There is an ineffective process in place to ensure the Golden Life policy is being adhered to. Licensing has noted that there is not a current Criminal Record Check(CRC) or authorization for an employee which the Licensing Officer has reviewed the file. There is an ineffective process in place to ensure that all current employees renew their CRC every 5 years and that the facility has a copy on their employee file. Medication Administration Record (MAR) review found inadequate responses to PRN effectiveness according to the policy of the medication safety and advisory committee. Non-compliance with PRN effectiveness has been noted on 4 consecutive inspections. Licensing has noted that E-Mar has been implemented recently and initial review shows improved compliance with this.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • 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)
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
      • R3.1AB - Keep all criminal record check results and character references for other persons for the entire time that the subject of the criminal record check or character reference is ordinarily present on the premises; 92( 3 )(b)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): Licensing has noted irregular performance appraisals in employee records. This is an ongoing infraction since Dec 2014. There is an ineffective process in place to ensure that Performance Appraisals are being conducted according to the Golden Life Policy. Licensing has noted that the CRC is not current and for an employee which the Licensing Officer has reviewed.
      • R4.4A - Keep employee criminal record check results; 86(a)
      • R4.4D - Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing observed fridge temperature logs with irregular temperature noted and no follow up documented. This does not ensure that the food in these fridges are safely stored.
      • 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): Licensing has noted scuffed and badly chipped walls, doorways and flooring noticeably worn in Person in Care (PIC) rooms and common areas throughout numerous neighbourhoods. Licensing observed unsecured sharp knifes in two common kitchen areas accessible to PIC. This has been noted during 2 previous inspections. (CDI) Licensing observed Clorox wipes in the cupboard in the staff room accessible to PIC (CDI) Licensing noted that during the inspection numerous tub room were accessible to PIC through a common bathroom door which was not secured. PIC were accessible to hazardous materials which were not safely secured and stored.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • 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)
  24. Monitoring

    11 infractions

    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): A review of employee records identified missing requirements according to the TB control program. The manager indicated that she is in the process of reviewing the auditing tool and collecting missing information. Non-compliance with TB control program has been noted on 2 consecutive inspections.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): Licensing observed the 24 hour care record available to Persons in Care (PIC), family and visitors in three neighbourhoods. In one neighbourhood, the chart room door latch was taped open allowing access to PIC, family, and visitors to private and confidential records.
      • Respect personal privacy and keep records and personal information confidential.
    • 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): Care plan review noted: -Process in place is ineffective to identify and develop a plan to address behavioural interventions for PIC who have been identified as a risk for aggression. -Process in place is ineffective to identify and ensure the persons at risk of leaving facility are identified and a elopement care plan is implemented. Non-compliance for elopement care plans has been noted on 2 consecutive since inspections.
      • 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.
    • 25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): Incomplete behavioural and elopement care plans in place for PIC who have been in care for greater than 30 days. Elopement care plans not in place for those PIC identified as elopement risk, elements missing to provide a plan to prevent or locate the PIC of they were to leave the facility.
      • Ensure care plans are developed within 30 days.
      • Ensure care plans include all required elements.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing observed ongoing non-compliance in five areas since the previous inspection. Descriptions are in the body of the inspection report. Licensee's monitoring of the physical environment and the care and services is ineffective.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): -Licensing observed irregular performance appraisals in employee records. -Medication Administration Record (MAR) review found inadequate responses to PRN effectiveness according to the policy of the medication safety and advisory committee. Non-compliance with PRN effectiveness has been noted on 2 consecutive inspections.
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
      • Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing observed the 24 hour care record available to Persons in Care (PIC), family and visitors in three neighbourhood computer desks. In one neighbourhood, the chart room door latch was taped open allowing access to PIC, family, and visitors to private and confidential records. Non-compliance with record confidentiality has been noted on 2 consecutive inspections.
      • Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): Licensing observed incomplete TB screening in employee records. Non-compliance for employee TB screening has been noted on 2 consecutive inspections.
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Communal clippers found in spa room with an ineffective cleaning protocol. Non-compliance with maintaining health and hygiene has been noted on 2 consecutive since inspections.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing observed: -hazardous sharp knife left in unlocked drawer-accessible to PIC. -Jim Smith neighbourhood chart room door latch was taped open, thus allowing access by PIC's to the personal belongings of employees and there was hazardous cleaning agents on the counter.
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 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): Care plan review noted: -Process in place is ineffective to identify and develop a plan to address behavioural interventions for PIC who have been identified as a risk for aggression. -Process in place is ineffective to identify and ensure the persons at risk of leaving facility are identified and a elopement care plan is implemented. Non-compliance for elopement care plans has been noted on 2 consecutive since inspections.
      • Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
  25. Monitoring

    8 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Unable to locate signatures on treatment records of multiple person in care files. Unable to locate effectiveness of "as needed" medication on multiple person in care files.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Unable to locate record of influenza vaccine and tuberculosis screening on multiple staff files.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Unable to locate record of immunization status and tuberculosis screening on multiple person in care files.
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Daily snacks do not consistently contain items from 2 food groups. Availability of fresh fruit and other healthy snack options is not posted for person in care/family.
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Unlabelled/communal clippers and brushes noted in spa room.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Hot water food warmers in servery areas are accessible to persons in care with water temperatures measuring up to 62 degrees celsius. Unlocked hazards including open cupboard containing nail polish remover and tubroom with chemical cleaners. One courtyard does not include shelter from the weather, no overhang or "roof" for shade or protection from precipitation. Medicated creams and eye drops located unlocked in multiple person in care bedrooms.
      • 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 outside activity areas that have comfortable seating including a reasonable amount of shelter from sun and inclement weather; 36 ( 1 ) (c)
      • Ensure all medications are safely and securely stored; 69( 3 )(a)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Door between tubroom and publically accessible bathroom not locked during assisted bathing of person in care Persons in care do not routinely carry identification on outings.
      • Ensure respect for personal privacy of each person in care, including privacy of each person’s bedroom, belongings and storage area; 53
      • 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 )
    • 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): Inadequate behavioural care plan on person in care file; individual deemed to be a risk for aggressive behaviours.
      • Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
  26. Monitoring

    9 infractions

    • 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): At times the staffing patterns and call bell response do not promote the health, safety and dignity of persons in care.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Several infractions noted during this inspection have been outstanding since 17-March-2014 and others since 29-Jul-2014. The Licensee must regularly monitor the physical environment of the facility and the care and services provided by it to ensure they meet the requirements of the Act and the Residential Care Regulation 61.
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Performance reviews not up-to-date on staff records reviewed this date. Ensure that the performance of each employee is reviewed both regularly to ensure that the employee continues to meet the requirements and demonstrates the competence required for the duties the employee is assigned as per Residential Care Regulation 40 (1) (a) (b).
    • 3.2 Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): At times, staffing patterns do not promote the health, safety and dignity of persons in care as per Residential Care Regulation 42 (1) (a) (b).
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): In one neighbourhood a staff person was not wearing a mask correctly thus exposing the nose and mouth. The Licensing officer questioned the employee if they were wearing the mask because they did not have a flu vaccination and the staff person indicated that was correct. The Licensing Officer told the staff person that the mask needed to cover the nose and mouth to be effective and a infraction would be made. The Licensee must ensure persons employed in the community care facility are in compliance of the Province's Immunization programs as per Residential Care Regulation 39 (1).
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): 1) In one neighbourhood, the wood railing has been scraped and wood splinters are present. Ensure all rooms and common areas are maintained in a good state of repair as per Residential Care Regulation 22 (1) (c). This infraction has been outstanding since 29-Jul-2014 and is NOT RESOLVED as of 08-Dec-2014. 2) Three of the four balconies did not have snow removal. In addition one balcony area had large icicles hanging down from the roof which is overhead directly to the balcony. All balcony doors were unlocked for residents to access. Ensure common areas are maintained in a safe condition as per Residential Care Regulation 22 (1) (c). 3) The left side of the front entrance to facility has what appears to be pigeon feces, cigarette butts and other debris present. Ensure all common area areas maintained in a safe clean condition as per Residential Care Regulation 22 (1) (c). 4) In one resident's room the floors had been washed however there was no signage to indicate the floors were wet. Ensure all common areas are maintained in a safe condition as per Residential Care Regulation 22 (1) (c). 5) Unsafe or inadequate storage of hazardous products: In three areas of the facility hazardous products were accessible to persons in care. Areas included an unmarked shower room with two hazardous cleaning products accessible; an open storage room door which allowed access to cleaning products, acetone, and a staff's purse; an unlocked kitchenette cupboard which had several cleaning products accessible. In addition when the Licensing Officer return to one of the neighbourhoods the same storage door was found open which again allowed access to hazardous products to persons in care. This infraction has been outstanding since 29-Jul-2014 and has NOT RESOLVED as of 08-Dec-2014. 6) Scissors were found in unlocked drawer at the nursing station which is accessible to persons in care. Please note this is an outstanding infraction since 29-Jul-2014 and is NOT RESOLVED as of 08-Dec-2014. 7) Fire extinguishers reviewed this date were expired as of September 2014. Ensure emergency equipment is maintained on a regular basis as per Residential Care Regulation 22 (3). 8) Please note that in the previous inspection done 29-Jul-2014 (4) Carpet stains noted in some neighbourhoods is RESOLVED as of 08-Dec-2014.
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): The licensee has provided persons in care with a monitoring or signalling device as per Residential Care Regulation 19 (1) (c) however once the monitoring or a signalling device signals to employees that the person in care needs immediate assistance, at times the response on some occasions does not promote the health, safety and dignity of persons in care.
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): 1) Inadequate storage of medications: Prescription creams found in some resident's rooms in unlocked cupboard accessible to persons in care. This infraction has been outstanding since 17-Mar-2014. NOT RESOLVED as of 08-Dec-2014. Ensure safe storage of all medications as per Residential Care Regulation 69 (3). 2) Medication administration record (MAR): PRN medications effectiveness or ineffectiveness not always documented. This infraction has been outstanding since 29-Jul-2014. NOT RESOLVED as of 08-Dec-2014. Ensure effectiveness or ineffectiveness of PRN medications are documented as per Residential Care Regulation 68.
    • 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): Before admitting a person into the community care facility, the licensee must consider as part of the process under the Residential Care Regulation 47 (2) subsection (1) (a) the numbers of employees and patterns of employee coverage.