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Mountain Lake Seniors Community Ltd.

908 11 St Nelson BC V1L 7A6 · Residential Care - Licensing

8 inspections

  1. Routine Inspection

    1 infraction

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system in place to ensure all rooms are in a good state of repair is ineffective. Licensing Officer noted a person in care's room to have extensive damage by the base boards. Portions of dry wall were noted to be damaged and pieces were missing in one area. Lack of room maintenance may negativity impact the dignity of the persons in care who reside in the room. Submit by June 5, 2025, a written plan outlining how you will address the maintenance issue in the room discussed during the inspection. The plan must include information as to how you will monitor the physical facility on an ongoing basis to ensure all rooms and common areas are in a good state of repair, thereby ensuring sustained compliance. The system in place to ensure all emergency exits are not obstructed is ineffective. Licensing Officer noted a hallway leading to an exit which had an area labelled for 'lift parking'. The following equipment was being stored in this area: a table, a broada chair, two walkers and two lifts. In discussion with the Manager, Licensing Officer learned that there is to be only one lift parked in this area. Having an excess of equipment stored near exits could hinder the ability to exit the facility in an emergency. Submit by June 5, 2025, a written plan outlining how you will ensure exits are free from storage of excess equipment. The plan must detail your ongoing monitoring measures which you will implement to ensure sustained compliance. The system for ensuring medications are safely and securely stored is ineffective. Licensing Officer noted medicated creams and ointments accessible in numerous persons in care's rooms. This was initially found to be out of compliance July 19, 2023, and is now an outstanding contravention. Access to prescription medications poses several risks to persons in care, especially those who may have cognitive impairments or other vulnerabilities. The immediate risk was addressed during the inspection as a facility wide audit was conducted and medicated creams and ointments were secured. Submit by June 5, 2025, a written plan outlining how you will ensure that all medicated creams and ointments are safely and securely stored. The plan must include the system you will implement to support ongoing monitoring to ensure sustained compliance.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
  2. 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): The complainant expressed concerns that not enough was being done to ensure the safety of a resident after an incident occurred. Licensing officer reviewed the incident, the applicable care plans, progress notes and other related documents. Licensing officer was able to determine that an intervention outlined in a plan of care was not followed in one instance. Licensing finds this complaint to be Substantiated.
      • 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

    2 infractions

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The weekly menus were posted, however, the menu posted in one cottage was for week 1, the menus in two other cottages were from week 4 and the rest of the cottages were displaying week 3. In a random review, licensing noted medicated creams and ointments to be left in unsecured locations.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(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): In a random audit of care plans, licensing noted a plan outlining the fact that a person in care is able to smoke in the designated area. However, there was very little information in the plan as to what this process looks like.
      • 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)
  4. 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 system in place for ensuring all persons in care (PICs) have an oral care plan which guides staff as to what care is required appeared ineffective. Licensing noted some care plans had limited information and did not indicate the type of care required, or how often to provide it. The system for ensuring that all persons in care who have been screened as an elopement risk, have an elopement care plan in place as per section 81(3)(f) of the RCR appeared to ineffective. Licensing noted that one PIC, who had been screened as an elopement risk, did not have an elopement care plan in place to guide staff as to what actions to take to prevent the PIC from leaving, or how to locate them if needed.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
      • 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)
  5. 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 system for ensuring that all care plans are reviewed, at minimum annually, appeared to be ineffective. Licensing officer noted one behavioural care plan was overdue for review. In addition, three managed risk agreements were noted to be overdue for review. The system being used to flag residents noted to have aggressive tendencies appeared to be ineffective. Resident records (chart, care plan) were not visually flagged as per the licensee's process.
      • 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)
  6. Monitoring

    6 infractions

    • R6.1 - Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): See number R3 above.
      • R6.1A - Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing noted that the name of the interim manager is not posted in the facility.
      • 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)
    • 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): As previously indicated in the report, not all residents carry written identification when they go off-site - RCR 56(1).
      • 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 current system in place to ensure policies are reviewed/revised, at minimum annually, appears to be ineffective. Licensing reviewed the policy manual in the communication room. Some updates had been made in the policy manual, however, the system in place to indicate that an annual review had been completed was not being utilized and therefore LO was unable to ascertain that it had occurred. The medication policy manual in the communication room did not reflect the updated policies from the new pharmacy noted to be in the gathering room.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system for ensuring staff are screened per the legislative requirements appears to be ineffective. In a random audit of staff files, licensing noted that that the immunization status of an employee was not recorded.
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system to ensure residents carry ID appears to be ineffective due to the fact that it does not currently include when family or friends take residents out of the facility without staff.
      • 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 )
  7. Monitoring

    8 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): Licensing observed that the housekeeping cart has hazardous chemicals accessible to PIC with no way to secure the chemicals. Licensing observed the Life Enhancement office was left open and noted to have unknown personal belongings accessible to PIC which is a potential access to hazardous materials (CDI) It was noted during the inspection that the tub room door was left open allowing access to PIC to cleaning agents. (CDI)
      • Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): Licensing observed that the Gathering Room was left unlocked and allowed access to personal and confidential information to PIC, family, and visitors. The report information is on a clip board, and the care files are kept in this office area.
      • Respect personal privacy and keep records and personal information confidential.
    • 25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): Licensing observed that PIC who have been deemed a potential risk to leave the facility do not have ID on their person at all times. Licensing observed that PIC who leave the facility do not have written documentation including name, facility name, emergency contact in their possession.
      • 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): Licensee's monitoring the physical environment to provide equipped areas for the secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials is ineffective. This is noted in the body of the report.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing observed that the "Gathering Room" was left unlocked and allowed access to personal and confidential information to Person's in Care (PIC), family, and visitors. The PIC report information is on a clip board, and there are PIC files which are kept in this area.
      • 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
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing observed that the housekeeping cart has hazardous chemicals accessible to PIC with no manner to secure the chemicals. Licensing observed the Life Enhancement office was left open and noted to have unknown personal belongings of employees accessible to PIC which is a potential access to hazardous materials (CDI) It was noted during the inspection that the tub room door was left open allowing access to PIC to cleaning agents. (CDI)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Licensing observed that there is an ineffective system in place to ensure that PIC who leave the facility unannounced have written documentation or an ID bracelet to provide information about PIC if they could not identify themselves.
      • 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 )
      • 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)
    • 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 ensure the persons at risk of leaving facility are identified and a elopement care plan is implemented.
      • 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)
  8. Monitoring

    4 infractions

    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): On a random audit of resident charts, three residents were noted to be missing TB screening and three different residents were noted to be missing vaccination status. This remains outstanding from the previous inspection report.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 (1)
    • 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): The Outbreak Prevention and Control policy was overdue for review/revision.
      • Review and, if necessary, revise policies and procedures at least once a year; 85(1)(b)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): In one cottage the rubber base board (trim) in the lounge area was torn away. In the same lounge, on the opposite side of the room, the base of one of the walls is chipped and damaged. A weekly menu was not posted in one of the cottages.
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
      • Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 (4)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): In one cottage LO could not find evidence of a medication room inspection.
      • Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68(2)(a)(b)