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McCulloch Residence

5500 McCulloch Rd Kelowna BC V1W 4G1 · Residential Care - Licensing

9 inspections

  1. Routine Inspection Follow-up

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Licensing received a reportable incident on April 23, 2026 and the report stated that the involved person in care’s physician was not notified that they were involved in a reportable incident. Licensing directed the Licensee Representative to report the incident to the physician. The Licensee Representative then reported to Licensing when the physician notification had been completed. If the physician is not immediately notified of a reportable incident, they are unable to assess the status of the person(s) in care and follow up accordingly. The Licensee will submit an updated Compliance Plan by June 11, 2026 outlining the systems and monitoring that will be put into place to ensure physicians are notified immediately when their patients are involved in a reportable incident in compliance with the legislation on an ongoing basis. Licensing was not immediately notified of a reportable incident of neglect. The report was submitted to Licensing approximately one month after the incident and did not contain the required information; details leading up to the incident and a plan to mitigate risk as per the directives in the reportable incident form. The Licensee Representative identified the incident on approximately March 24, 2026 and notified the Licensee of the incident on April 21, 2026 at which time the Licensee put an immediate Health and Safety Plan into place, and directed the Licensee Representative to report to Licensing. If Licensing is not immediately notified of a reportable incident Licensing Officers are unable to assess level of risk to persons in care and follow up accordingly. The Licensee will submit an updated Compliance Plan by June 11, 2026 outlining the systems and monitoring that will be put into place to ensure that reportable incidents are reported to Licensing immediately in compliance with the legislation on an ongoing basis.
      • R4.5F - Immediately notify the medical or nurse practitioner responsible for the person in care involved in a reportable incident; 77( 2 )(b)
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Self-monitoring did not occur to ensure a Compliance Plan that was put into place to address a previous incident was followed as per the details in the body of this report. If a Compliance Plan is not followed there is an increased risk of negative outcomes to the health, safety, and/or dignity of persons in care. The Licensee will submit an updated Compliance Plan by June 11, 2026 outlining the systems and monitoring that will be put into place to ensure that the Compliance Plan is followed so that care is provided in compliance with the legislation on an ongoing basis.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee Representative identified an incident of neglect during a routine review of in-house video surveillance on approximately March 24, 2026. The video showed that on March 22, 2026 a person in care required immediate assistance with their clothing as failure to do so posed a high risk of a fall occurring. The Licensee Representative did not report the incident of neglect to Licensing until April 23, 2026. During Licensing’s investigation the Licensee Representative reported that the person in care was not provided assistance for 30 minutes. Licensing reviewed a seven minute section of the video and noted that two employees were present and repeatedly walked past the person in care without providing assistance. If a person in care is subject to neglect it may result in serious harm to the person in care. The Licensee will submit an updated Compliance Plan by June 11, 2026 outlining the systems and monitoring that will be put into place to ensure person(s) in care are not subject to neglect in compliance with the legislation on an ongoing basis.
      • R10.2D - Ensure persons in care are not subjected to financial, emotional, physical, sexual abuse or neglect; 52( 1 )(a)
  2. Routine Inspection

    1 infraction

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The Licensee does not have a system in place to ensure records are kept for minor accidents, illnesses, and unexpected events involving persons in care. If records of minor incidents are not kept the Licensee and/or Licensing may not be able to follow-up as required which is a risk to the health, safety or dignity of persons in care. The Licensee will submit a Compliance Plan by April 22, 2026 outlining the systems and monitoring that will be put into place to ensure that records of minor incidents are kept in compliance with the legislation on an ongoing basis.
      • R4.5K - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(a)
      • R4.5L - Retain a record of unexpected events involving persons in care; 88(b)
  3. Routine Inspection Follow-up

    10 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): During the inspection it was noted that the upstairs bathroom was in the process of being renovated. Licensing was not provided an incident report regarding a potential service delivery issue as required, and the facility Licensing Officer was unaware that these renovations were taking place. Historical complaint allegations of neglect were not reported to Licensing as required. In the licensee's submission of August 12, 2025 (in response to the Preliminary Findings), they state " We do not feel that any items (the general manager) lists in (the) record of the March 1, 2024 meeting were of such severity they warranted a Licensing Report for neglect or abuse." This record references a complaint and lists concerns including: - Ignoring and neglecting (person in care) while (they were) crying out for long periods of time. - Not attending to (person in care) according to care plans and helping (person in care). - Tilted back at 60 degrees having a difficult time breathing, putting (them)at risk for choking. - Bed not tilted correctly, keeping wheelchair brakes on for extended periods of time. - Not engaging with the individuals in a therapeutic manner. The licensee response does not demonstrate an understanding of the Residential Care Regulation, specifically section 77 (1)(a)(ii) which states: "For the purposes of this section, a person in care is involved in a reportable incident if the person in care (a) is the subject of (i) a reportable incident, or (ii) in the case of reportable incidents of emotional, physical, financial or sexual abuse, or neglect, an alleged or suspected reportable incident" The Regulation provides specific definitions of the types of incidents that must be reported to Licensing, including any alleged incidents of abuse and neglect. This provides Licensing the opportunity to review incidents and provide support and oversight to the licensee when required. Submit by September 9, 2025, confirmation and evidence that the licensee and licensee contact have reviewed Section 77 of the Regulation, including schedule D definitions of reportable incidents, and completed a revision the facility's Policies and Procedures to incorporate the regulatory requirements for reporting of reportable incidents to Licensing. Provide evidence of a system put into place for ensuring all reportable incidents are immediately reported to Licensing as required, and include who, when, and how this system will be monitored to ensure sustained compliance.
      • 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): The observation of current systems in place showed no system to monitor documentation to ensure it is completed as required. Interviews with staff, the general manager and house manager indicate that there is no system in place to ensure documentation is completed. The general anager and house manager advised that they try to review the Medication Administration Records (MAR) and documentation on a regular basis, but it was noted that documentation was not always completed. Specifically, there was no documentation for a July 6, 2025, outing or progress notes completed by the involved staff as required per the facility's policies and procedures. The involved staff file was reviewed and it was observed that there was no criminal record check (CRC) available. The house manager was eventually able to locate the CRC; however, the CRC obtained when the employee was initially hired was not able to be located. The systems to ensure that the staff record requirements are complete are inadequate. While the licensee stated a video surveillance system was in place to review care processes, the facility lacks an audit system to demonstrate how this footage is reviewed. The current system in place for the monitoring and evaluating of staff performance is inadequate. There was no documented evidence for the monitoring, evaluating or performance management of an employee with several serious concerns, and four medication errors on file from October 2024 to April 2025. Other than having involved the staff re-read the medication policy, there was no evidence provided to indicate how the involved staff was monitored. Failing to have effective systems in place to monitor the provision of care presents a risk to the health and safety of persons in care. Submit by September 9, 2025, evidence that supports how the facility will ensure that there are systems in place to ensure that the care and services is monitored. Please include the requirement to identify who, when, and how they will monitor the system put into place to ensure sustained compliance.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • RB1.18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): Please R10.1a and R10.1b - Standards to be maintained (connected to Section 7 (1)(b)(i) and (ii) of the Community Care and Assisted Living Act)
      • RB1.18A - Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • 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 involved staff did not complete documentation as as required by the facility's policies and procedures, including progress notes and activity log entries. The licensee contact did not follow the investigation procedures outlined in facility policy A8. Misconduct and Abuse. Specifically, the facility's internal investigation was not discontinued after Licensing approved a Health and Safety Plan that included the removal of the involved staff, and it was agreed that Licensing would investigate the reportable incident. A failure by the licensee to implement the facility's Policy and Procedures (in this case documentation and investigation processes) increases the risk to persons in care's dignity, as well as their physical and emotional health and safety. Submit by September 9, 2025, evidence of systems put into place to monitor/audit and document staff implementing and following the facility's Policies and Procedures. Include a system that identifies who, when, and how ongoing monitoring of this new system to ensure compliance is sustained.
      • 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 involved staff had not received a performance evaluation in four years. The involved staff's file was incomplete and lacked a criminal record check, references and a resume. A current criminal check was provided during the inspection as it had been recently applied for. The licensee contact stated that the staff file was incomplete due to a break in employment. In addition, there was no resume or references as the licensee contact advised that the involved staff was hired based on reference from a facility staff member. The Residential Care Regulations for staff records are in place to ensure staff are appropriately qualified for the position they are applying for. Appropriate reference checks ensure that hired staff have the required experience and temperament required for the position. Performance evaluations provide to identify skills, learning gaps and opportunities, or any possible opportunities for career progression. Additionally, these requirements when implemented ensure licensees monitor, document, and appropriately address performance concerns, as well as aid the licensee during progressive discipline processes. Submit by September 9, 2025, evidence that staff records and performance evaluations are complete. Include a system that identifies who, when, and how ongoing monitoring of this new system to ensure compliance is sustained.
      • 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)
      • R3.1E - Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37( 1 )(d)
      • R3.1N - 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)
      • R3.1Q - Designate an employee qualified by training and experience to supervise employees who provide care to persons in care, coordinate and monitor the care of persons in care and manage unusual situations or emergencies; 41( 2 )(a)(b)( c)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): Please see R3.1. Staff records were not retained. The involved staff was previously employed by the facility and the employment file was not retained. The licensee contact was unable to demonstrate compliance with the Regulation and confirm that all the required records were obtained and was unaware of the requirements. Retention of records are required to demonstrate continued compliance with the Regulation. Submit by September 9, 2025, evidence that employee records are retained for the time periods required. Describe how this system identifies who, when, and how ongoing monitoring of this new system to ensure compliance is sustained.
      • R4.4A - Keep employee criminal record check results; 86(a)
      • R4.4B - Keep employee character references; 86(b)
      • R4.4D - Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • R4.6 - Are facility records current and complete?
      • Observation(s): The criminal record check, work experience documentation and reference checks for the involved staff were not retained as required. Retention of records are required to demonstrate continued compliance with the Regulation. Submit by September 9, 2025, evidence that criminal records and reference checks are retained for the time periods required. Describe how this system identifies who, when, and how ongoing monitoring of this new system to ensure compliance is sustained.
      • R4.6R - Retain all records for at least one year (except original forms authorizing criminal record checks, employee character references, records for persons in care and records of complaints); 92 ( 1 )
    • 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): The involved staff employed a practice not identified in the care plan which did not ensure the health, safety and dignity of persons in care. By placing a cloth bandana in the person in care's mouth, there was potential for choking and also prevented the person in care from vocalizing. The involved staff had been involved in previous allegations of neglect and had a history of performance management issues. The investigation process followed by the licensee and licensee contact regarding the reportable incident was deficient. Interviews were conducted via text messaging and there was not a standard process to avoid evidence contamination. Despite Licensing agreeing to take over the investigation, and the licensee committing to a Health and Safety plan by removing the involved staff from the facility, the licensee continued their investigation and brought the the involved staff back to demonstrate care procedures on a person in care. Despite the involved staff being alleged to have provided sub-standard care in past, (including documented medication errors and allegations of neglect), the licensee contact was unable to demonstrate what corrective actions and monitoring measures were put in place to address the concerns brought forward. While the licensee maintains that a progressive discipline model was followed, this is not supported by the documentation reviewed. Employment records for the involved staff were not obtained and retained by the licensee, as required. Reference checks for the involved staff were not obtained as required. Staff did not follow a person in care's care plans and engaged in high risk practices; specifically doing sling transfers with one person only. The care plan stated 2 persons for sling transfers. The licensee contact confirmed that this practice was occurring, and submitted that after the unexplained injury, this policy and care plan requirements would be "enforced". While the licensee contact was aware that this practice was occurring, there was no action taken to ensure the care plan was being followed and this practice discontinued. The licensee contact confirmed employees do not receive orientation or training on abuse and neglect. The licensee failed to provide documented evidence of systems in place to ensure staff's knowledge and understanding of the facility's Abuse and Neglect Policy. The legislation and Bill of Rights are in place to ensure the health, safety and dignity of persons in care and that their rights are protected. A licensee is obligated to ensure that their facility is operated in a manner that promotes these rights. Submit by September 9, 2025, a plan and system to ensure that standards are maintained and person in care rights are promoted. Describe how this system identifies who, when, and how ongoing monitoring of this new system to ensure compliance is sustained.
      • R10.1A - Promote the health, safety and dignity of persons in care; CCALA 7( 1 )(b)(i)
      • R10.1B - Promote the rights of adult persons in care: CCALA 7( 1 )(b)(ii)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The licensee provided evidence that the involved staff provided rushed care. Video evidence for July 8, 2025 indicated that the involved staff was not using care and attention while moving the Person in Care (not using wheelchair brakes and bumping into a step stool). The involved staff performed a full clothing change on the person in care in 9 minutes, while other staff stated it would take 20-30 minutes when completed correctly. During this care routine, the involved staff put a small pair of shorts on the person in care, which did not belong to them. Other staff later noticed that the waist band of the shorts was digging into the person in care's waist area and causing discomfort. Photographic evidence indicates the marks left by the wait band. In an interview with Licensing, the involved staff was unable to accurately describe how the shorts were put on during the care routine. The staff interviewed provided the following information regarding the involved staff "takes a lot of short cuts". The involved staff shows a "no care attitude", and was observed providing rushed care, ignoring person in care needs, and not mixing medication properly with care and attention. Staff described instances where the involved staff changed the television channels to their preferred programming (for example anime and violent movies) when Persons in Care were watching their preferred programming (for example " SpongeBob"). The involved staff did not deny doing this, and attempted to rationalize his actions claiming that the persons in care liked violent programs. The involved staff was the subject of a neglect complaint March 1, 2024 (see R. 4.5 above). In addition, the facility substantiated that the involved staff subjected a person in care to unauthorized care where injuries were were sustained due to shaving their body parts. On a balance of probability, the evidence indicates that the involved staff was neglectful in the care provided to a person in care, resulting in injuries. A licensee must ensure that persons in care are not subjected to harmful actions such as abuse and neglect. Submit by September 9, 2025, a plan to ensure that persons in care are not subjected to harmful actions. Describe how this system identifies who, when, and how ongoing monitoring of this new system to ensure compliance is sustained.
      • R10.2D - Ensure persons in care are not subjected to financial, emotional, physical, sexual abuse or neglect; 52( 1 )(a)
    • 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 person in care's care plan (updated June 2024) requires a two person assist for transfers. Staff, house manager and licensee contact confirmed that the care plan was not followed, and only one person transfers were performed. A failure to follow a person's care plan increases the risk to the health and safety of persons in care. Sling transfers are a high risk task, hence the requirement for two person assist. Submit by September 9, 2025 a plan to ensure that care plans are followed by staff. Describe how this system identifies who, when, and how ongoing monitoring of this new system to ensure compliance is sustained.
      • 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
  4. Routine Inspection

    1 infraction

    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): January 26, 2024 Contravention - The Licensee does not have a system in place to ensure that person in care’s status changes and the actions taken in response are documented. It was noted during the inspection that one person in care was given a prn medication for a status change. It was documented that the person in care’s status was the same after the administration. There was no documentation available for review by Licensing as to who had authorized the administration of the prn, or what actions had been taken in response to the ineffectiveness such as an assessment. One care plan was reviewed and noted to be in compliance with the legislation.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  5. Routine Inspection

    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): March 4, 2020 -The Licensee has a system in place to ensure that the supervising pharmacist conducts audits as per facility policy however; there is no system in place to ensure that meeting minutes are retained, and that any recommendations and/or education are communicated to the employees. The Licensee has a system in place to ensure employee orientation to the Residential Care Regulation, and the Manager reported that the system for how the employees review the Regulation will be updated.
      • R2.1N - Establish and review policies and procedures on safe and effective storage, handling and administration of medications; 68( 3 )(b)(i)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): March 4, 2020 -The Licensee meets at least annually with the representatives however; an opportunity is not offered for the representatives to meet with the Licensee as a group to promote the collective and individual interests of the persons in care.
      • R10.2S - Provide at least an annual opportunity for councils, or if no council is established, as a group, to meet with the licensee to promote the collective and individual interests of the persons in care and involve the persons in care in decision making on matters that affect their day to day living; 59(b)(i)(ii) (Show More)
  6. Monitoring

    2 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): May 9, 2018 -It was noted during the inspection that the facility did not have a system in place to ensure that reportable incidents were reported to Licensing in the manner required. Four reportable incidents had been submitted to Licensing within the past three years, and all were noted to be missing required information.
      • 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)
    • 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): May 9, 2018 -It was noted that the facility did not have a system in place to ensure that managers and employees were orientated to the Community Care and Assisted Living Act, and the Regulations.
      • 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)
  7. Monitoring

    4 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): On person in care's care plans, written consent for the use of restraints from the person in care or their representative was not in place. When discussing this with the House Manager, it was apparent that only verbal consent from person in care's representatives has been obtained.
      • 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)
    • RB1.9 - Are persons in care able to have family or a representative participate on the resident or family council on their own behalf?
      • Observation(s): An opportunity has not been formally provided for the persons in care and their parents/representatives to form a council or meet at least once annually as a collective.
      • RB1.9A - Ensure persons in care are able to have family or a representative participate on the resident or family council on their behalf.
    • RB1.10 - Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
      • Observation(s): Please refer to RB1.9 (above).
    • R4.6 - Are facility records current and complete?
      • Observation(s): The Licensee has made contact with each person in care's representatives to provide them with an opportunity to comment on the care being provided; however, an opportunity has not been formally provided for the persons in care and their parents/representatives to form a council or meet at least once annually as a collective. This issue was also identified on previous inspection reports for 2015 and 2016.
      • R4.6H - Retain records of compliance with family and resident council required in section 59; 89( 2 )(b)
  8. Monitoring

    8 infractions

    • 9 - Are persons in care able to have family or a representative participate on the resident or family council on their own behalf?
    • 10 -Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
      • Observation(s): Please see comments in report.
    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Feb. 18, 2016 -It was noted that the Policy on Reportable Incidents still referred to the Adult Act. This was corrected during inspection to refer to the Residential Care Regulations. NEW INFRACTIONS -It was noted that the facility policies did not include a plan to address emergencies other than fire. -It was noted that the facility is not following its policy for "Annual Forums".
      • Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
      • 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)
      • Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): OUTSTANDING from April 2014 -It was noted that admission height and weight is not documented in the person in care's charts. The manager reported that the first documented height and weight will be added to the charts. -It was noted that monthly weights were not being recorded for 2 persons in care.
      • Record the height and weight of each person in care on admission; 49 ( 2 )
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 4.6 Are facility records current and complete?
      • Observation(s): OUTSTANDING from May 7, 2015 -It was noted that the facility does not maintain records of family/resident council meetings.
      • Retain records of compliance with family and resident council required in section 59; 89( 2 )(b)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): NEW INFRACTION from Feb. 18, 2016 -It was noted that in one person in care's room the wardrobe was placed in front of the window. The manager reported that the wardrobe had been placed in front of the window to prevent the person in care from causing self-harm with the blind cord. The manager reported that a new plan will be put into place that allows the window to be exposed. A safety covering will be devised and put into place.
      • Each bedroom must meet the needs of and provide for the health, safety and dignity of the occupant; 26 ( 1 )
      • Each bedroom must have a window that provides natural light, with coverings to block light and protect privacy; 28 ( 1 )
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): NEW INFRACTIONS from Feb. 18, 2016 -It was noted that a resident/family council meeting was not offered as per RCR 59, and facility policy (annual forums) -It was noted that documentation was in place for the change in status of 2 persons in care, and documentation to indicate the condition was being monitored could not be located.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • Provide at least an annual opportunity for persons in care and their parents or representatives, family members and contact persons to establish councils or similar organizations to represent the interests of persons in care; 59(a)
      • Provide at least an annual opportunity for councils, or if no council is established, as a group, to meet with the licensee to promote the collective and individual interests of the persons in care and involve the persons in care in decision making on matters that affect their day to day living; 59(b)(i)(ii) (Show More)
    • 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): NEW INFRACTIONS from Feb. 18, 2016 -It was noted that one person in care would sit at a specific table, and sit quietly in this area when upset, however this was not included in the care plan. -It was noted that 2 persons in care had the same recreation plan; they were not specific to the persons in care, and they had not been reviewed within the past year. -It was noted that care plans contained outdated seizure protocol and Physio directive.
      • Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • Care plans must include a recreation and leisure plan; 81( 3 )(d)
      • Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
      • 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. Monitoring

    13 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): 07-May-2015-It was noted that physician orders and documentation regarding restraints were not present in the persons in care's charts.
      • 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)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): 07-May-2015-Unable to locate documentation for the use of restraints (seat belts).
      • Record the type or nature of the restraint used in the person's care plan; 84(a)
      • Record the reason for the use of restraint in the person's care plan; 84(b)
      • Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • 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)
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): 07-May-2015- TB screening is resolved, however immunization status remains OUTSTANDING.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 (3)
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73(2)c
      • Provide in the care plan a plan to address, if there is agreement to the use of restraints, the type or nature of restraint and the frequency of reassessment; 81(3)(a)(iii)
    • 1 - Are all policies and procedures available to persons in care?
      • Observation(s): Refer to report.
    • 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): Does not apply to community living.
    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): 07-May-2015-It was noted that the Incident Report Policy was outdated, referring to the Adult Guardian Act. All policies inspected did not indicate that they had been reviewed/revised within the past year. 07-May-2015-It was noted that the facility was not following it's policy on restraints regarding documentation, and PRN medication effectiveness was not always documented. 07-May-2015 -It was noted that documentation for monthly fire drills for the last 5 months could not be located. RESOLVED-faxed to Licensing May 15, 2015
      • Review and, if necessary, revise policies and procedures at least once a year; 85(1)(b)
      • Ensure policies are implemented by employees; 85(1)(d)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): 07-May-2015- Missing performance evaluations - OUTSTANDING - from the April 30, 2014 inspection.
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40(1)(a)(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): RCR 49 - OUTSTANDING from 30-Apr-2014
      • Record the height and weight of each person in care on admission; 49 (4)
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): RCR 86(d) OUTSTANDING from 30-Apr-2014
      • Keep employee character references; 86(b)
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 4.6 Are facility records current and complete?
      • Observation(s): RCR 59 - OUTSTANDING from 30-Apr-2015
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 (3)
      • Retain records of compliance with family and resident council required in section 59; 89(2)(b)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): 07-May-2015-It was noted that there was damage to the walls in the upstairs elevator hallway. 07-May-2015-It was noted that there was damage to the wall in one resident's room.
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
    • 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): RCR 83(1)(a)(3)(a) OUTSTANDING from 30-Apr-2015 - The manager reported that there is a plan in place to develop and maintain nutrition plans.
      • 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)
      • 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)