Kootenay Street Village
620 Kootenay St N Cranbrook BC V1C 3T9 · Residential Care - Licensing
7 inspections
- Routine Inspection Follow-up
1 infraction
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): R1.1W - In reviewing the compliance plan accepted by Licensing on November 26, along with the documented evidence and on‑site discussion, it is noted that one portion of the plan is not currently implemented as outlined. The plan specifies that a designated form is to be used for follow‑up with employees regarding missed temperature records. While the temperature logs show a noticeable improvement in compliance, the required form for missed recordings has not been utilized. Documented evidence indicates that the remaining components of the plan to address Residential Care Regulation, Section 61 are implemented as written. Failure to implement the compliance plan as submitted and accepted by Licensing increases the risk of continued non-compliance with regulatory requirements and may result in ongoing or repeated contraventions. Without a process to complete and review audits, the risk that ineffective practices or non-compliance will go unidentified and unaddressed increases, potentially impacting the health and safety of persons in care. Submit by March 9, 2026, a new written plan outlining how the contravention related to ensuring the physical environment is regularly monitored has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 61 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection
3 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): R1.1W - Of the records reviewed, including the August 2024 compliance plan and temperature logs there, was no evidence to indicate that the licensee had implemented the monitoring system as outlined in the Compliance Plan that was submitted, and accepted by, Licensing on August 22, 2024. The licensee has an established audit schedule; however, upon review, it was noted that audits have not been completed as outlined in the schedule. It was also identified that the licensee does not have a system in place to review audit results to evaluate the effectiveness of existing systems or to identify the cause of any deficiencies. Failure to implement the compliance plan as submitted and accepted by Licensing increases the risk of continued non-compliance with regulatory requirements and may result in ongoing or repeated contraventions. Without a process to complete and review audits, the risk that ineffective practices or non-compliance will go unidentified and unaddressed increases, potentially impacting the health and safety of persons in care. Submit by November 10, 2025, a written plan outlining how the contravention related to ensuring the physical environment and the care and services provided are being regularly monitored, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 61 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- 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): R2.1S - Review of records found no evidence that topical medication administration records were in place or signed as required by the licensee's medication administration policy. Not maintaining topical medication administration records as outlined in policy increases the risk of non-compliance with medication management requirements and may compromise safe medication practices. Submit by November 10, 2025, a written plan outlining how the contravention related to ensuring policies are implemented by employees, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 85(1)(d) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- 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): R10.3A - A review of care plans indicated that behaviour care plans did not include the specific and unique behaviours of the individuals to which the outlined interventions were associated. It was noted that the interventions identified within the care plans were individualized and tailored to the persons in care. When specific behaviours are not identified within the care plan, there is a risk that employees may not have a clear understanding of the behaviours being addressed, leading to inconsistent or inappropriate implementation of interventions and potential harm to persons in care. Submit by November 10, 2025, a written plan outlining how the contravention related to ensuring care plans take into account the unique and individual needs of the person 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, internal incident reports, and progress notes identified that an employee provided one-person care when the care plan specified that the person in care required a two-person assist. Additionally, a review of care plans and completed assessments noted that assessments were not conducted at the frequency outlined in multiple care plans. Failure to follow a care plan increases the risk that care will be inconsistent or inappropriate, potentially compromising the safety, well being, and health of the person in care. Submit by November 10, 2025, a written plan outlining how the contravention related to ensuring that 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
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection
2 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The system to ensure the care and services provided are regularly monitored is ineffective. Self monitoring documents related to previous contraventions were reviewed during this routine inspection. It was noted that these documents did not contain any documented corrective actions to address identified non-compliance. Through random chart audits, and a review of documentation on site, it was noted that a care plan focus for accessing the community independently was not accessible to all employees.
- 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 a review of documentation on site, it was noted that the policy related to the frequency of completing the Dementia Observation System (DOS) Tool was not being implemented.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection
3 infractions
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): It was noted during the inspection that the system to ensure policies are implemented by staff is ineffective. This was identified through the review of fridge and freezer temperature logs where procedures were noted to have not been followed.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): It was identified during the inspection that the system to monitor fridge and freezer temperatures to ensure safe storage of food is ineffective. This was noted by inconsistent completion of required temperature logs.
- 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): During the inspection medicated creams were noted on a nightstand, and bathroom sink in a person in care's room. Corrected during inspection.
- R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Routine Inspection
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): The licensee currently does not currently have a system in place to ensure persons in care who leave the facility independently have a plan in place. During the inspection the licensee did develop a plan for a person in care who accesses the community independently. This plan included the process the person in care follows to notify staff, the process for staff to follow should the person in care not return at agreed upon time, and the steps to follow before initiating a Code Yellow.
- 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)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Routine Inspection
1 infraction
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): During the inspection an over the counter medicated cream was noted on the nightstand in a person in care's room. Corrected during inspection.
- R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
- R9.1 - Are medications stored, handled, and administered appropriately?
- Routine Inspection
4 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): A person in care who has a restraint care plan did not have the consent of the person in care, or their representative. The restraint consent form only had the authorization of the Most Responsible Physician. Please provide licensing with the system the facility will incorporate to ensure that all restrain authorization includes consent from the person in care or the representative, as well as the Most Responsible Physician. 74(1)(a)(b)(i)(ii)
- R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): The tracking system to monitor the use of restraints was noted to be missing signatures for a 4-day period. The system to monitor staff's compliance with the restraint care plan and tracking system was not effective. Please provide licensing with the systems the facility will utilize to ensure that restrains are monitored and tracked as per RCR 73(1)(c) and the facility policy.
- R10.4C - Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The most recent routine monitoring inspection report was observed to be located in a glass picture frame, high on the side wall beside the reception desk. Consequently, the report was not accessible in its entirety, nor was the report posted in a prominent place in the care facility. Please provide licensing with how the routine monitoring inspection will be posted as per RCR 11(1)(b).
- 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)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): It was observed that an employee who has been with the facility for more than 3-months did not have a 3-month performance evaluation, as per the facility policy. Please provide licensing with what tracking systems the facility will utilize to ensure performance evaluations are completed on employees as per the facility policy. RCR 40(1)(a)(b)
- 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)
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?