Skip to content
Loading map…

Maples Satellite Program

210 Cypress Dr Coldstream BC V1B 2Y1 · Residential Care - Licensing

1 inspection

  1. Routine Inspection

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system to ensure medication administration records are accurately completed is ineffective. A review of a medication administration record identified a missing signature for the date a PRN was administered. Failure to ensure complete medication administration records, including required staff signatures, poses a potential risk to the health and safety of persons in care by limiting the licensee's ability to confirm safe and accurate medication administration practices in accordance with established policies and regulatory requirements. Submit by February 06, 2026, the plan that will be implemented to come into compliance with Section 78(2)(b) of the Residential Care Regulation. The plan must include your process for ongoing monitoring of the updated system.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 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 an Emergency plan sets out how to continue care for persons in care is ineffective. A review of the Emergency Preparedness plans did not contain plans for the continuation of care beyond the evacuation of persons in care to a marshalling point outside the facility. There was no plan setting out how persons in care will continue to be cared for in the event of an emergency. It is essential in time of an emergency that staff have direction and information on how and where persons in care will continue to be cared otherwise this possesses a potential health and safety risk to persons in care. Submit by February 06, 2026, the plan that will be implemented to come into compliance with Section 51(1)(b) of the Residential Care Regulation. The plan must include your process for ongoing monitoring of the updated system. The system to ensure that all policies and procedures are followed is ineffective. A review of the Daily task lists Identified sporadically missed signatures. Incomplete checklists may indicate that processes and checks were not completed as required. Submit by February 06, 2026, the plan that will be implemented to come into compliance with Section 85(1)(d) of the Residential Care Regulation. The plan must include your process for ongoing monitoring of the updated system.
      • 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)
      • 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 to ensure that a persons in care's weight is record on admission is ineffective. During a review of person in care’s records, it was identified that there was no system in place to record a persons weight on admission. Without an initial record of height and weight, care staff lack a baseline to track changes in a person in care’s nutritional status which can be indicators of underlying health issues. Accurate and complete admission assessments, including height and weight are critical for developing individualized care plans. Missing information may lead to gaps in care or interventions that are not tailored to person in care needs. Submit by February 06, 2026, the plan that will be implemented to come into compliance with Section 49(2) of the Residential Care Regulation. The plan must include your process for ongoing monitoring of the updated system. The system to ensure that records for each person in care contain the required information is ineffective. During a review of client identification sheets, it was noted that there was no picture of the person in care. The absence of identifiers such as a picture poses a potential safety risk to the person in care. Submit by February 06, 2026, the plan that will be implemented to come into compliance with Section 78(1)(d) of the Residential Care Regulation. The plan must include your process for ongoing monitoring of the updated system. The system to ensure that persons in care have consented to the facility calling a medical practitioner or ambulance in case of an accident or illness is ineffective. During a review of a care plans there was no evidence of written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness. Consents are required to ensure that the rights of the person in care are respected. Submit by February 06, 2026, the plan that will be implemented to come into compliance with Section 78(3)(a) of the Residential Care Regulation. The plan must include your process for ongoing monitoring of the updated system. The system to ensure that persons in care are weighed monthly is ineffective. During a review of person in care's records, it was identified that there is no system in place to record monthly weights. Incomplete weight monitoring increases the risk that significant changes in person in care's health status may go unrecognized or unmanaged. Missing documentation can delay timely assessment and intervention, potentially compromising the safety and well being of the person in care. Submit by February 06, 2026, the plan that will be implemented to come into compliance with Section 83(4)(a) of the Residential Care Regulation. The plan must include your process for ongoing monitoring of the updated system.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • R4.1I - 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)
      • R4.1L - Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
      • R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The system to ensure that a nutrition plan for each person in care is developed is ineffective. A review of Care plans identified no nutrition plans for persons in care. Failure to develop a nutrition plan for each person in care can compromise staff's ability to meet persons in care's current and individual nutritional needs. Submit by February 06, 2026, the plan that will be implemented to come into compliance with Section 83(1)(a) of the Residential Care Regulation. The plan must include your process for ongoing monitoring of the updated system.
      • R10.3N - Develop a nutrition plan for each person in care and review the plan on a regular basis (Applies to a facility with 24 or fewer persons in care); 83( 1 )(a)( 3 )(a)