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Mt. Cartier Court

1200 Newlands Rd Revelstoke BC V0E 2S0 · Residential Care - Licensing

11 inspections

  1. Routine Inspection

    5 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): While reviewing medication administration records, observed staff signatures missing from documentation. When administration of medication is not consistently documented, there is increased risk of medication errors and negative health impacts for persons in care. Submit a corrective action plan by July 9, 2026, indicating how the licensee will ensure all medication administration records are complete.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): While reviewing two care plans for two-hour restraint monitoring documentation, noted several instances of monitoring documentation missing. This is a repeated contravention. Lack of restraint monitoring and documentation has potential to physically and emotionally harm persons in care. Submit a corrective action plan by July 9, 2026, indicating how the licensee will ensure a system is in place for restraint monitoring throughout the use of the restraint and assessed after the use of the restraint.
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): RCR 54(1) A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene. Nail clippers observed loose on counter in tub room. Staff disposed of nail clippers during inspection. When nail clippers are not kept separately for each person in care, there is risk of transferring communicable disease between persons in care. Submit a corrective action plan by July 9, 2026, indicating how the licensee will ensure nail clippers and other personal use items are stored in manner to maintain the health and hygiene of all persons in care. RCR 63(1) A licensee must ensure that all food is safely prepared, stored, served and handled. While reviewing servery cooler/freezer temperature log documentation, observed several fridge and freezer temperatures documented greater than safe food storage critical limits, with no corrective action documented. When food is not stored at safe temperatures and monitored to ensure same, there is increased risk of food borne illness for persons in care. Submit a corrective action plan by July 9, 2026, indicating how the licensee will ensure food is safely stored.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
      • 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): Gate in a courtyard observed open. Staff closed gate during inspection. When outside areas are not secured, there is increased risk of persons in care exposure to environmental, health, and safety hazards. Submit a corrective action plan by July 9, 2026, indicating how the licensee will ensure all outside areas are secured.
      • R7.1AO - Ensure the outside activity area is secured by a fence or other means, if necessary to protect the health and safety of persons in care; 36 ( 2 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Observed handwritten medication administration records for several persons in care, including one without a date. Staff reported that pharmacy supplies stickers for medication changes that do not fit on current medication administration record documentation form. When medication administration records are not recorded by a pharmacist, there is increased risk of medication errors and detrimental health effects for persons in care. Submit a corrective action plan by July 9, 2026, indicating how the licensee will ensure that a pharmacist records all medications on the person in care's medication administration record.
      • 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)
  2. Routine Inspection

    2 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): During a review of restraint documentation for three persons in care, it was observed that the Restraint Monitoring and Documentation tool, for three persons in care, had no record of restraint initiation and subsequent monitoring when restraints had been applied. The use of a restraint without assessment and monitoring puts persons in care's safety and physical and emotional dignity at risk. Submit by April 17, 2025, evidence that for all persons in care requiring a restraint, Restraint Monitoring and Documentation has been initiated and subsequent monitoring is completed.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): During an audit of hot water temperatures, the hot water in two persons in care's bathrooms was measured at 57 and 58 degrees Celsius. Water temperature exceeding 49 degrees Celsius presents risk for immersion burn. Submit by April 17, 2025, evidence that water accessible to persons in care does not exceed 49 degrees Celsius.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
  3. Routine Inspection Follow-up

    4 infractions

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): The system to ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of persons in care is ineffective. This is evidenced by not having sufficient nursing staff (LPN) coverage between 2300 hours on December 29, 2024, and 0700 hours on December 30, 2024, and sufficient care staff coverage (HCA) between 0500 and 0700 hours on December 30, 2024.
      • R3.2A - There must be sufficient numbers of trained and experienced employees on duty at all times. Staffing patterns must meet the needs of persons in care and assist persons in care with activities of daily living, including eating, mobility, dressing, grooming and hygiene in a manner consistent with the health, safety and dignity of persons in care; 42( 1 )(a)(b) (Show More)
    • 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 that policies are implemented by employees is ineffective as evidenced by employees not following the previously implemented Working Short Plan which references Minimum Staffing/Baseline Staffing Chart guidelines.
      • 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 system to ensure that a licensee designates an employee, qualified by training and experience, to supervise employees who provide care to persons in care, is ineffective. It was reported that between 2300 hours on December 29, 2024, and 0700 hours on December 30, 2024, there was no designated employee on premises to supervise employees who provide care to persons in care. The system to ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate, is ineffective. It was reported that between 2300 hours on December 29, 2024, and 0700 hours on December 30, 2024, there were no staff on premises who held a valid first aid and CPR certificate.
      • 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)
      • R3.1R - 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)
    • 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 care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan is ineffective. It was reported by the charge nurse that at 0630 hours on December 30, 2024, the restraint and falls prevention care plans, for one person in care, were not implemented.
      • 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

    7 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): The system to ensure that a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing, by both the representative of the person in care, and the medical practitioner responsible for the health of the person in care, is ineffective. On review of one person in care's records, and confirmed by facility leadership, there were no agreements to the use of a restraint given in writing.
      • 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)
    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system to ensure that a medication administration record showing the date, amount, and time at which the medication was administered is ineffective. On review of medication administration records, for several persons in care, required documentation was not present.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The system to ensure that if a person in care is restrained the duration of the restraint, and the monitoring of the person in care during the use of the restraint, is recorded in the care plan of the person in care is ineffective. On review of one person in care's records the required documentation was not present.
      • 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)
    • 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 that policies are implemented by employees is ineffective. It was observed that one person in care's My Day, which was located in their room, was not updated as directed by facility policy.
      • 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 system to ensure that all employees comply with the policies and procedures of the medication safety and advisory committee is ineffective. A review of medication administration records identified several instances where PRN (as needed) medication effectiveness was not documented.
      • R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system to ensure that all food is safely stored is ineffective. On review of the facility's monitoring records of fridge and freezer temperatures, it was observed that several temperature monitoring entries were missing.
      • 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): The system to ensure that all rooms and common areas are maintained in a safe condition is ineffective. It was observed that one area of the concrete pathway, in the courtyard outside of Cottage D, poses a tripping hazard. The system to ensure that all medications in the community care facility are safely and securely stored is ineffective. At the time of the inspection, two prescription treatment creams were located on counters in separate bathrooms, and accessible to persons in care.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
  5. Routine Inspection

    5 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Previous inspection report was not posted.
      • 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): Performance evaluations are not being completed as required. This is a repeat contravention.
      • 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)
    • R4.6 - Are facility records current and complete?
      • Observation(s): Manager unaware of food service auditing requirements and no recent food service monitoring records (including food satisfaction surveys) were available.
      • R4.6D - Retain the results of monitoring of food services and nutrition care; 87(c)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Water in PIC washrooms was measured at 54 and 52 degrees during readings taken in two cottages. (corrected during inspection) Paint on wall chipped and damaged in hallway adjacent to servery; uncovered light with wires observed in same area. (requisition made to fix during inspection) Facility has upgraded many night tables in PIC rooms which do not have locks on them.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 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): Restraint monitoring charting is not being completed consistently in line with the restraint care plan. (This is a repeat contravention).
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  6. 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): It was noted that fire drills are not conducted monthly (as per IH policy). In the last 12 months, there were 4 months where a fire drill was not conducted. Fire drills are conducted by the maintenance department. This is a recurring contravention from the previous inspection. During the inspection, it was noted on several Medication Administration Records (MARs) for persons in care that the effectiveness of as needed (prn) medications is commonly not assessed and documented as per IH policy and procedure.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): During the inspection, it was noted that one person in care has ongoing room tray service. The ongoing room tray service was not indicated in the care plan for the person in care, there was no approval from the person in care's medical/nurse practitioner, and no reassessments were conducted.
      • 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)
  7. Monitoring

    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): The system for ensuring monthly fire drills are completed is ineffective. There are no completed fire drills on record since June of 2017.
      • 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 system in place for ensuring performance evaluations are completed is ineffective. The Manager stated that she has not been able to complete performance evaluations since her return from a leave of absence. This remains outstanding from previous inspection reports.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system for ensuring hazardous materials are secure is ineffective. Staff purses were noted to be stored on the shelf in one of the dining rooms. Unknown hazardous materials, objects or medications could be stored in these purses which are accessible to persons in care.
      • 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)
  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): The process for ensuring compliance with clear and up to date immunization records is ineffective. Several person in care records were reviewed during the inspection. The section related to diphtheria, tetanus, influenza and pneumococcal were left blank on several person in care records. The Licensing Officer discussed the process of documentation and the offering of the pneumococcal vaccine as per IHA policy with the RN on duty. There is a binder that has some documentation of the past years influenza immunization and some documentation of pneumococcal status, but it was unsure if pneumococcal vaccines were offered to every person in care. The tetanus and diphtheria status was also unknown.
      • 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
    • 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): In reviewing the orientation check off sheet, it was noted that orientation to the regulations and the Act was included for the RNs and the LPNs only.
      • 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)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The manager stated that performance evaluations are continued to be worked on but are not complete at this time. The plan is to complete one evaluation per week. This remains outstanding from previous inspection reports.
      • 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)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The process for monitoring emergency equipment is ineffective. It was noted that the fire extinguishers in the facility were due for service on or before September 21, 2016. The process for monitoring and safe storage of hazardous materials is ineffective. Containers of Cavi Wipes were found on the shelf at the nursing station and on a shelf in one of the community kitchens and were accessible to persons in care.
      • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
  9. Monitoring

    11 infractions

    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Staffing template was incomplete for immunization and tuberculosis screening on several staff members.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 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): As noted previously in this report - there has not been a Family Council meeting since October of 2014.
    • 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): As noted previous in this report - the most recent routine inspection was not posted.
      • Post the most recent routine inspection in a prominent place.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The inspection report from February of 2015 was posted. There was another inspection conducted in September of 2015 which was not posted.
      • 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)
    • 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): In the fire drill documentation submitted by the manager it was noted that fire drills did not occur monthly on several random months over the past year. Fire drills are to occur on a monthly basis as per Interior Heath policy.
      • 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): Staffing template spreadsheet for care staff is incomplete. Several staff were missing character references, work history, copies of certificates and diplomas and performance reviews have not been completed. There is no staffing template completed for support staff to indicate the same as noted above including criminal record checks.
      • Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • Obtain character references for all employed persons; 37( 1 )(b)
      • Obtain a record of work history for all employed persons; 37( 1 )(c)
      • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37( 1 )(d)
      • 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): Several person in care records were missing height weight, eye and hair color on the information sheet.
      • 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)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Wall damage was noted in several person in care rooms in Cottage B. This remains outstanding from the previous inspection.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • 10.1 Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): Several unlabeled toiletries were noted in the bathing rooms throughout the facility including skin protection creams, nail clippers, shampoos and powders. This remains outstanding from the previous inspection.
      • Promote the health, safety and dignity of persons in care; CCALA 7( 1 )(b)(i)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There have been no family council meetings since October of 2014.
      • 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)
    • 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): A person in care records indicated that the person in care was assessed as an elopement risk and a high risk for falls . The care plan was not updated with this information. Follow up date for this item is March 25, 2016. Several nutrition care plans have not been reviewed for greater than 1 year. It was discovered that there is a gap in the assessment information getting on to the care plans of the persons in care. The manager is to follow up on this.
      • 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)
      • Develop, with the assistance of a dietician, a nutrition care plan for each person in care and review the plan with a dietician on a regular basis (Applies to a facility with 24 or more persons in care); 83( 2 ), 83( 3 )(b)
  10. Monitoring

    8 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): There were several missed signatures noted on the Treatment Administration Record (TAR) for several regularly scheduled treatments on several person in care records. There is noted improvement on the signing of the TARs, from the last inspection but this remains an ongoing issue.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): Restraint written agreement form was completed and signed by the representative along with a order from the doctor in regards to a restraint being used on a person in care. There was no restraint documentation in the care plan of the person in care, nor was there any documentation being completed by staff in regards to the monitoring of the restraint while the restraint was being used. This was discussed with the nurses during the inspection.
      • 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)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): In reviewing the incidents reported to Licensing, it has been noted on several occasions that notifications and details are incomplete as well incident reports are late being submitted 56% of the time during the last year.
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • 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 noted in the inspection report under care and supervision
      • 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): As previously noted in the report.
      • Respect personal privacy and keep records and personal information confidential.
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): There were missed monthly weights on the sampling of person in care records reviewed during the inspection. This was discussed and reviewed with the nurse during the inspection. Follow up for this item is Oct. 9, 2015. There are kardex's and persons in care documentation binders left out on tables in the dining/living areas of each separate community that has personal information accessible to people other than staff. Staff are not always in these areas to monitor who has access to the information.
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
      • 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): Damage noted to the walls in several person in care rooms, several hallways and living areas throughout the facility. It was noted during the inspection that there were several inconsistencies with the temperature of a medication fridge with the temperature reading below the safe range determined by the medication policy. Several cups of covered food as well as yogurt and ensure was is also being stored in the medication fridges in the communities. Follow up for this item is Oct. 9, 2015
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Ensure all medications are safely and securely stored; 69( 3 )(a)
    • 10.1 Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): There was a garden hose in one of the outside areas that was not coiled up all the way and part of the hose was laying on the sidewalk posing a safety risk to persons in care accessing this area. A fridge was noted in the bedroom of a person in care. Temperature monitoring of this fridge is noted to be very sporadic on the log. Baskets containing unlabeled toiletries including underarm deodorant, creams and hairbrushes were found in one of the tub rooms.
      • Promote the health, safety and dignity of persons in care; CCALA 7( 1 )(b)(i)
  11. Monitoring

    11 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Missing signatures were noted the Treatment Administration Record for a regularly scheduled treatment cream in a persons in care room.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78(2)(b)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): Several missed entries were noted on the restraint monitoring schedule in the person in care records. The care plan indicated that the scheduled monitoring is to be done when the restraint is in use.
      • 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)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Missing TB screen documentation on staff tracking tool. This item remains outstanding.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 (13)
    • 16 - Are persons in care who make prepayments provided written terms and conditions under which a refund may be made?
      • Observation(s): As per noted in the inspection report itself.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The manager stated that all of the staffs first aid certificates had expired last October and the manager has had discussions with Residential Services about this with no resolve in meeting the requirements of section 43 of the Residential Care Regulation. As per section 61 of the Residential Care Regulation - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 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): It was determined that payments for the services being provided are prepaid but there is no written statement available for Licensing to review in regards to setting out the terms and conditions on which a refund will be paid.
      • Keep a current record of each person to whom the written statement is delivered as referred to in section 19 of the Act; 85.1 (2)(b)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Staff files are not kept on site. The manager has a tracking tool but not all of the information has been completed on the tool. Some Criminal Record Checks noted to be missing on the tracking tool. The facility has been focussing on obtaining measles, mumps and rubella screening. TB screening is not being completed on the tracking tool. Performance evaluations have not been completed. Manager reported that staff first aid certificates expired last October. Staff first aid requirements are a priority and a compliance plan will need to be submitted to Licensing. This remains outstanding since the past inspection. A compliance plan was discussed during the inspection and is to be submitted to Licensing. Fire drills are not taking place on a monthly basis. It was noted since the last inspection that fire drills were not conducted in September and December of 2014 and January of 2015.
      • Ensure criminal record checks are obtained for all employed persons; 37(1)(a)
      • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37(1)(e)
      • 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)
      • 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)
      • Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 (15)
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): Please see Staffing section 3.1 in regards to staffing records on each employee. The tracking tool being used at the facility is incomplete in meeting the requirements of this section. This item remains outstanding.
      • Keep employee criminal record check results; 86(a)
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Community A - a plate of sandwiches was stored in fridge without a date label. At 1:45 p.m. in Community D - cream soup and desserts were left on the kitchen counter accessible to persons in care. There was a large almost empty container of what looked like to be applesauce stored in the fridge without a date label. The monitoring of the bar fridges in the persons in care rooms is not being completed on a regular basis. The current plan in place is for monthly monitoring and one fridge noted to have over seven weeks in between checks. Safety of this monitoring plan was discussed with the manager, as monthly monitoring is not adequate to alleviate the risk of other persons in care having access to items such as alcohol or expired foods stored in these fridges. This item remains outstanding.
      • Ensure that food is safely prepared, stored, served and handled; 63 (13)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It was discussed by teleconference with the maintenance man, the checking and routine monitoring of the exit doors. The front exit door is checked every day but the outside exits to the garden areas are not being routinely checked or monitored. The facility does not have an audit tool in place for this. The facility is to ensure there are safety measures and audit tools in place promoting the health and safety of all persons in care. (a copy of the Safety Bulletin from Sue Bedford dated from 2011 will be attached to the email along with the inspection report)
      • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signaling devices; 22 (15)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Persons in care who are a known risk for wandering are not wearing any means of identification on them. This item remains outstanding.
      • 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)