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Lake Country Lodge Community & Retirement Living

100-10163 Konschuh Rd Lake Country BC V4V 2M2 · Residential Care - Licensing

7 inspections

  1. Routine Inspection

    0 infractions

  2. Routine Inspection

    0 infractions

  3. Routine Inspection

    0 infractions

  4. Routine Inspection

    3 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): December 7, 2018 The facility's system for ensuring compliance with restraint policies was noted to be ineffective. Representative consent for the use of a restraint that was currently in place was signed in 2014. Moving forward the Clinical Lead reported that all persons in care's representative consent for the use of a restraint will be reviewed during the annual care conferences.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): December 7, 2018 The facility did not have a system in place to ensure that all legislated requirements were in place and care planned for for the persons in care who were provided with ongoing room tray service. The Clinical Lead reported that a plan will be put into place to audit and update records for all persons in care receiving ongoing room tray service
      • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): December 7, 2018 The facility's system to ensure that care plans are updated with a substantial change in status was noted to be ineffective. During an audit of a care plan it was noted that a person in care required a post-surgical device and the care plan and "my day" did not reflect this change. The Clinical Lead reported that a plan will be put into place to audit and monitor charts and "my day" for updates and consistency.
      • 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)
  5. Monitoring

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): December 15, 2017 -It was noted that the facility did not have a system in place to monitor that Medication Safety and Advisory Committee recommendations were being implemented by staff, that an outstanding exemption request was submitted, and that a policy was in place to guide the orientation of managers and staff to the regulations and the Act.
      • 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): December 15, 2017 -It was noted that the facility could not locate a policy that required the orientation of new managers and employees to the regulations and the Act. A nurse orientation check list was reviewed, and it was noted that it did not include orientation to the regulations and the Act.
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): December 15, 2017 OUTSTANDING FROM THE PREVIOUS INSPECTION: -It was noted during the April 6, 2017 inspection that bathroom doors in some resident's rooms had been removed and replaced with a curtain. An exemption request application was requested to be submitted and education was provided by Licensing on how to apply for an exemption. An incomplete exemption request was submitted. Licensing continued to provide education and request the missing information, however the missing information was not submitted, and this infraction remains outstanding. As this infraction remains outstanding since April 6, 2017 a completed exemption request is requested to be submitted immediately. -The facility put a system into place to monitor the environment for the safe storage of medications, however the system was noted to be ineffective. An audit was conducted on July 3, 2017 and unlocked medications were noted in multiple rooms. There is no documentation of follow-up or staff education as a result of this audit. The audits are not regularly scheduled and another audit was conducted again on September 5, 2017. Again unlocked medications were noted in multiple rooms with no documentation of follow-up or staff education. The audits indicate that unlocked medications continue to be accessible to residents.
      • R7.1AB - Bathrooms must have a door with a lock that can be opened from the outside in case of an emergency; 30(a)
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): December 15, 2017 -It was noted that a system is not in place to ensure that MSAC meeting minutes are received from the Pharmacist, and that the Pharmacist's recommendations are communicated to the staff.
      • R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)
  6. Monitoring

    9 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): April 6, 2017 -The facility did not have a system in place for ensuring resident's charts are in compliance with agreements to the use of a restraint. The residents who were using restraints did not have written agreement from the residents or their representatives.
      • 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): April 6, 2017 -The facility's system for ensuring that restraint documentation is in compliance is ineffective. It was noted that a record of monitoring a resident while in a restraint could not be located.
      • 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)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): April 6, 2017 -The facility's system for ensuring compliance with the immediate reporting of reportable incidents is ineffective. It was noted that fifty percent of the reported incidents in 2016 were received by Licensing more than 48 hours after the incident had occurred.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): April 6, 2017 -The facility's system for ensuring that the manager's name was posted was ineffective. This was corrected during inspection. The last inspection report was posted, however it was posted inside a picture frame and could not be read by residents or families. During the inspection the manager removed the report from the frame and posted it in a manner that could be easily read.
      • 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)
    • 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): April 6, 2017 -The facility's system for ensuring that resident's charts are completed as per facility policies and procedures is ineffective. It was noted that one resident's chart had an oral health assessment that was not signed or dated. On-line documentation indicated that the resident had declined dental hygienist care, however the facility form that the family/representative signs to indicate that they have accepted or declined the care could not be located. -The facility's system for ensuring that staff are orientated to the regulations and the Act are ineffective. One staff member reported that they had not been orientated to the regulations and the Act.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): April 6, 2017 -The system for ensuring that resident's charts are in compliance is ineffective. It was noted that admission height was not documented in the resident's chart that was reviewed. This is outstanding from the September 24, 2015 inspection.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
    • R4.6 - Are facility records current and complete?
      • Observation(s): April 6, 2017 -The facility's system for ensuring compliance with medication safety and advisory committee records is ineffective as a record from the last meeting could not be located.
      • R4.6A - Keep a copy of each policy and procedure of the medication safety and advisory committee; 85 ( 3 )
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): April 6, 2017 -The facility's system for ensuring that the residents maintain hygiene is ineffective. It was noted that two residents who share a room had their toothbrushes in the same container. This is outstanding from the September 24, 2015 inspection. This was corrected during inspection. The residents require assistance with oral hygiene, and a system was put into place to prevent the residents from accessing and combining the toothbrushes in the same container.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): April 6, 2017 -The facility's system for ensuring compliance with the safe storage of medications and hazardous equipment is ineffective. It was noted that prescription treatment drops, scissors, and the kitchen were accessible to the residents. The facility submitted an email on April 7, 2017 stating that the system for accessing the kitchen had been changed and that the kitchen was no longer accessible to the residents. -The facility's system for monitoring the physical environment for compliance with the Regulations is ineffective. It was noted that some of the resident's bathrooms did not have a door with a lock.
      • R7.1AB - Bathrooms must have a door with a lock that can be opened from the outside in case of an emergency; 30(a)
      • R7.1AJ - Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 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)
  7. Monitoring

    4 infractions

    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): First Aid certificates noted to be expired on two staff files.
      • Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Unable to locate admission height and weight on multiple person in care files. OUTSTANDING Unable to locate identifying description on multiple person in care files. Elopement warning poster noted of outside door containing person in care photo and name.
      • Record the height and weight of each person in care on admission; 49 ( 2 )
      • Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
      • Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Toothbrushes unlabelled/stored communally in multi-person bathrooms.
    • 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Unable to locate nutrition plan for a person in care.
      • Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)