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Mulberry Place

2803 39 St Vernon BC V1T 6J3 · Residential Care - Licensing

8 inspections

  1. Routine Inspection

    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 to ensure that all policies and procedures are followed is ineffective. A review of the ‘Wellness and Safety check Daily Records’ identified checklists for safety checks, restraint monitoring and turning schedules which were not fully completed as per policy. Ensuring policies and procedures are followed was also a contravention on the last inspection. Incomplete checklists may indicate that checks were not completed as required which is potentially a safety risk to person in care. Submit by October 24, 2025, the plan that will be implemented to ensure ongoing compliance with Section 85(1)(d) of the Residential Care Regulation.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system for maintaining the physical environment in a good state of repair is ineffective as noted by peeling paint as well as dents and damage to walls. The flooring throughout the facility is worn-out. It was also noted that in one person in cares bedroom an electrical outlet cover was broken. Maintaining the physical environment was also a contravention on the last inspection. Regular maintenance is important to ensure the ongoing health, safety and dignity of persons in care. Submit by October 24, 2025, the plan that will be implemented for ongoing maintenance for the facility to ensure ongoing compliance with Section 22(1)(b) of the Residential Care Regulation.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • 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 monitor Care plans to ensure proper implementation was ineffective. During a review of Care plans, it was noted that an Oral Care plan required monitoring of the person in cares oral care twice daily with a follow-up monthly check. There was no evidence that the monthly checks were completed. Failure to ensure proper implementation of the care plan may compromise staff's ability to meet persons in care's current and individual needs. Submit by October 24, 2025, the plan that will be implemented to ensure ongoing compliance with Section 82 of the Residential Care Regulation.
      • 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
  2. Routine Inspection

    4 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The system to ensure that staff are monitoring and recording as per the care plan is ineffective. It was observed that restraint monitoring checklists were sporadically charted and incorrectly labelled. Bedrail monitoring for a person in care was also noted to be absent on a number of monitoring check lists.
      • 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 all policies and procedures are followed is ineffective. A review of the medication second check and the bowel movement records identified missing daily checks. Please ensure there is an auditing system in place to ensure ongoing compliance.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system for maintaining the physical environment is ineffective as noted by excessive wheelchair marks, dents and damage to walls and door frames. The facility walls, doors and door frames have not been painted in some time. Cable wires were observed to be exposed from a bedroom wall.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • 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 plans are reviewed at least once each year is ineffective. It was observed that a care plan indicated that it was last revised in May 2023. Please ensure that care plans are identified as having been reviewed / revised at least once yearly.
      • 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)
  3. Routine Inspection

    3 infractions

    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system to ensure monthly weights are recorded is ineffective as it was observed during a chart review that several monthly weights were missed.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system to ensure fridge and freezer temperatures are recorded is ineffective as several missed recordings were noted for the two freezers.
      • 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): It was observed that the outside area had a seasonal shelter from sun and inclement weather but that the fixture is taken down in the fall. Please ensure that persons in care have the ability to access a shelter from sun and inclement weather all year round.
      • R7.1AN - Provide outside activity areas that have comfortable seating including a reasonable amount of shelter from sun and inclement weather; 36 ( 1 ) (c)
  4. Routine Inspection

    0 infractions

  5. Monitoring

    6 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Immunization and tuberculosis screening were not in the records of several persons in care.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • RB1.22 - Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): As noted previously in the inspection report - persons in care information was posted on the fridge in the kitchen. The documentation was removed and this item was corrected during the inspection.
      • RB1.22A - Respect personal privacy and keep records and personal information confidential.
    • RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
      • Observation(s): As noted previously in the inspection report -safety equipment being used was not recorded in the care plan of 2 persons in care.
      • RB1.23A - Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
    • 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 during the inspection the general restraint policy was incomplete. This remains outstanding from the previous inspection report. It was noted during the inspection staff were not following the policy on safety equipment being used and was not being recorded in the care plans of persons in care. Although ensuring policies are implemented by employees was noted on the last inspection report, this item is a different policy. The Medication Safety and Advisory Committee has not met for over 1 year.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): It was noted during the inspection consents to call the medical or nurse practitioner or ambulance in case of an accident or illness was not on record. It was noted during the inspection documentation with persons in care information was posted on the fridge in the kitchen. The documentation was removed and this item was corrected during the inspection.
      • R4.1I - Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
      • R4.1S - 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
    • 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): It was noted during the inspection safety equipment being used was not recorded in the care plan of 2 persons in care.
      • 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)
  6. Monitoring

    3 infractions

    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): July 22, 2016 -It was noted that the home's system for notifying Licensing was ineffective as Licensing had not been notified that the manager had resigned.
      • Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
    • 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): July 22, 2016 -It was noted that the home's system for ensuring that policies are current and complete was ineffective as the reportable incident policy did not contain "choking", and the restraint policy was clear regarding emergency restraint but missing information on general restraint. The Acting Manager reported that Quality Management and HR will be notified regarding the incomplete policies. -It was noted that one care plan contained documentation referring to the Adult Guardian Act. This was CORRECTED DURING INSPECTION. -It was noted that the home's system for ensuring that staff follow policies was ineffective as the food substitution log could not be located at the time of inspection.
      • Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): July 22, 2016 -It was noted that the home's system for ensuring that food substitutions were documented was ineffective as the substitution log could not be located at the time of inspection. This was CORRECTED DURING INSPECTION. A menu substitution log was posted, and education was provided for staff. -It was noted that the home's system for ensuring that the posted nutrition menu was current was ineffective as the nutrition menu was noted to not be specific to the current persons in care.
      • Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
      • Provide adequate food to meet the personal nutritional needs based on Canada's Food Guide, and the person in care's nutrition plan; 66 ( 1 )
  7. Monitoring

    7 infractions

    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): Restraints being used on persons in care and were not included in the care plans nor was there any documentation being completed in regards to monitoring of the restraints.
      • 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)
      • Keep a record of employee compliance with the requirements of Division 5 (Use of Restraints) of Part 5 in the persons care plan; 84 (f)
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): One of the foot stools top cover was cracked and worn.
      • Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): As per noted above. Restraints being used were not included in the care plans of the persons in care.
      • Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 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 noted previously in the inspection report related to the garden watering hose left out on the ground in the back yard. This was corrected during the inspection.
      • Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Facility computer program with staffing information was made available to the Licensing Officer to review during the inspection. Specific boxes were designated for flu vaccines and TB testing. There was no box assigned for immunization to indicate if immunizations were screened for. Staff screening remains outstanding from past inspection report.
      • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Water temperature measured at 56 degrees Celsius. The manager immediately turned the temperature down on the hot water heater and will continue to follow up to ensure a safe temperature is established and maintained. Dishwashing pucks and rinsing agent found unlocked in the lower kitchen cupboard. Dishwashing pucks noted to be hazardous if swallowed. The manager immediately moved the dishwashing supplies to the shelf in the upper cupboard adjacent to the dishwasher which is out reach of of any persons in care. If there is a new admission or change in condition of any of the persons in care, the manager is to reassess the safety of this storage area to ensure the safety of persons in care. Currently there are no persons in care who can physically access the shelf of this upper cupboard.
      • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 10.1 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 water hose left out on the ground of the back yard across the patio/sidewalk area. The hose was stretched out over the distance of several meters. The manager immediately secured the hose out of access of persons in care.
      • Promote the health, safety and dignity of persons in care; CCALA 7( 1 )(b)(i)
  8. Monitoring

    8 infractions

    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Evidence of immunization and tuberculosis control program documentation not available.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 (1)
    • 8.1 Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Activity calendar did not include all activities offered in the home. There was only a few documented in house activities noted on the calendar.
      • Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55(1)(a)(i)
    • 8.2 Does the program of activities support individualized care plan requirements?
      • Observation(s): Activity calendar did not include all of the activities offered in house and only had a few documented activities noted.
      • Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55(1)(a)(ii)
    • 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): Policy on incident reports did not include "aggression between persons in care".
      • Review and, if necessary, revise policies and procedures at least once a year; 85(1)(b)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Limited staff records were available on the computer. Licensing officer was able to review First Aid Certifications on the records reviewed. All certifications were valid. Criminal record check was documented on some of the records with review date but not documented on all of the records reviewed. Reference check documentation was not available. Work history documentation was not available. Copies of diplomas, certificates or evidence of training and skills was not available. Immunization or tuberculosis documentation was not available. Performance evaluation documentation was not available. This infraction remains outstanding from previous inspection reports.
      • 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)
      • 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)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Facility has consent forms available but no signed consents were noted in the person in care records. This infraction remains outstanding from the past inspection.
      • Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78(3)(a)
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): As per above - documentation not available.
      • Keep employee criminal record check results; 86(a)
      • Keep employee character references; 86(b)
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 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): Oral care plans have not been reviewed for over 1 year.
      • 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)