Nelson Jubilee Manor
500 Beasley St W Nelson BC V1L 6G9 · Residential Care - Licensing
8 inspections
- Routine Inspection
3 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): During the inspection, Licensing Officer was made aware of an incident that had not been reported to licensing as required. Licensing Officer was able to confirm appropriate follow-up to the incident had occurred.
- 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)
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): The system to ensure that all persons in care have evidence of screening for TB appeared to be ineffective. In a random review of records, Licensing Officer noted two person in care's charts did not have record of TB screen on file.
- R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): The current Fall/Winter menu does not include any snacks as per section 62(2)(b) of the Residential Care Regulation.
- R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
2 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): The system for ensuring that the licensee is keeping records of the date and time at which medications are administered appeared ineffective. In random audit of Treatment Administration Records (TARs), licensing noted that there were numerous scheduled medications which were not documented as given.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(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 licensee does not currently have a dietician available regularly to review nutritional care plans. In a random review of nutritional care plans, licensing noted that some were due for review in October of 2022. Licensing noted the My Day care plans to be current. However, in a random review, licensing noted that some of the more detailed care plans (RAI) did not reflect the most recent quarterly review.
- 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)
- R10.3P - 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)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
3 infractions
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Upon a random review of person in care's medication records (MARs), the process for documenting "as needed" (PRN) medication effectiveness appeared to be ineffective. Evidence of the documented effectiveness could not be located in the MAR or the progress notes.
- R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Although there is a process for posting the daily menu in the dining area, the weekly menu is currently not posted in the facility. The system for ensuring hazardous items are securely stored appeared to be ineffective. Some items which were noted to be hazardous were located in unsecured areas.
- 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)
- R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): There currently is not a system in place to ensure that all persons in care who leave the facility for any purpose, have ID in their possession per section 56 of the RCR.
- 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 )
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Routine Inspection
3 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Upon a random audit of TARs, licensing officer noted that the system for ensuring that the date and time that medications are administered appeared to be ineffective. One TAR, which indicated a medication to be given once per day, reflected that the medication had only been administered two times in 9 days.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): The licensee's current system to meet the intent of the legislation pertaining to self-medication appeared ineffective. This was evidenced by noting the "self-administration of medication monitoring form" was in the residents' charts but not in the MAR and the "request to self-administer medication" form was noted in the records but not completed. One care plan was not clear in relation to the resident's self-medicating status.
- R9.1G - Permit self-administration of medication when a plan is approved by the medication safety and advisory committee and medical or nurse practitioner, and is included in the person's care plan; 70( 4 )(a)(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): Licensing officer noted that the care plans in person in care's rooms and the RAI care plans were current. However, a managed risk agreement and specialized care plans (showering, effective communication, and a safety plan) were noted to be due for review in 2018.
- 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)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
3 infractions
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): The system for ensuring that all residents have complied with the Province's immunization program is ineffective. Upon a random chart audit, no information had been documented for numerous residents' immunization statuses, other residents had a status for flu but not for pneumococcal and the majority of residents did not have a status documented beyond flu and pneumococcal.
- R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
- R6.2B - 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
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The system for monitoring the physical facility to ensure water temperatures do not exceed 49 degrees Celsius is not working. LO measured a temperature down the North wing at 53 degrees Celsius and down the East wing at 51 degrees Celsius.
- R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- 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): A new system is currently underway to ensure that care plans are reviewed quarterly, however, this system does not appear to be effective. One resident's care plan in their room was blank under the fall risk but in the kardex had fall risk interventions listed. Another resident's care plan in their room indicated that it had last been reviewed March of 2015 but in the kardex the date of review was July of 2016. Another resident had a behaviour care plan in their room which was not dated and in the kardex the same care plan had a review date of May 2015. The medication care plans in the MAR are not consistently dated when reviewed and therefore LO is unable to ascertain if the plan of medication administration is current. This is a RECURRING infraction. Please inform licensing of the changes you will make to the system and the method which you will use to monitor the effectiveness of the system to ensure continued compliance in this area.
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Monitoring
8 infractions
- 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): Upon a random audit of resident records, one resident was noted to be missing TB screening.
- Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
- 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): LO was unable to locate the most recent monitoring inspection report which was conducted June of 2015.
- 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): LO was unable to locate the most recent monitoring inspection report which was conducted June of 2015.
- 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)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): The effectiveness of PRN medications is not consistently being recorded.
- Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): One resident currently has access to the nursing station, while under supervision, to fulfill part of her care routine.
- 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
- 4.6 Are facility records current and complete?
- Observation(s): One resident's absence consent form was not completed.
- Ensure all records are current; 91( 1 )(a)
- 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): An undated jar of apple sauce was noted to be opened in the medication fridge.
- Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- 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): Some of the "Care Cards" were not consistently dated. Some of the "Care Cards" in the kardex had been updated but not transferred to the resident room copy. One resident had a fall prevention strategy in place at the bedside but it was not listed in their "Care Card".
- 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)
- 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Monitoring
4 infractions
- 7.2 Is the environment maintained to prevent falls?
- Observation(s): Down North and East wings, large flannel sheets were pinned up in the corridors covering the windows. This was done during the recent heat wave to keep the heat out.
- Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
- 10.4 Are restraint and fall prevention plans appropriate?
- Observation(s): Upon a random audit of care plans, one resident's falls care plan did not contain information regarding a recent update which was posted in the bathroom on a post-it-note.
- Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (Show More)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The resident washroom adjacent to the nursing station can be locked by residents while they are in the washroom. There is only one "key" in the nursing station to open this door and, at one time, the key could not located. A temporary key was replaced during the inspection.
- Bathrooms must have a door with a lock that can be opened from the outside in case of an emergency; 30(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): Upon a random audit of care plans, licensing officer (LO) noted that 3 residents had minimal information in their oral care plan (i.e. own teeth or dentures). There was no information for staff to indicate what type of assistance, if any, was needed.
- Care plans must includes an oral health care plan; 81( 3 )(b)
- 7.2 Is the environment maintained to prevent falls?
- Monitoring
3 infractions
- 2.2 Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): The incident reporting policy did not contain specific information indicating what constitutes a reportable incident (Schedule D).
- Ensure there are written policies and procedures regarding responding to reportable incidents; 85(2) (j)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The base board in one resident's room was noted to be splintered and cracked. CORRECTION DATE: MARCH 1, 2015. The hand rails down the North and East wings were noted to be splintered and cracked in some areas. Please provide a plan to licensing by MARCH 15, 2015. The carpet in the nursing station is taped up in numerous places and one area is ripped open. Please provide a plan to licensing by MARCH 15, 2015.
- Maintain all rooms and common areas in a good state of repair; 22(1)(b)
- Provide appropriately furnished and equipped areas for administrative work and other staff use; 35(1)(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): Although the medication care plans were thorough, they were not dated, therefore there is nothing to indicate that they are being reviewed/revised. CORRECTION DATE: FEBRUARY 1, 2015. Behaviour care plans were thorough and dated in the Kardex, but the duplicate care plan located in the residents room did not have a date. CORRECTION DATE: FEBRUARY 1, 2015.
- 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)
- 2.2 Are written policies and procedures in place to guide staff in fall prevention?