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New Meadows

Confidential · Residential Care - Licensing

7 inspections

  1. Routine Inspection

    2 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): A review of PRN (as needed) administration records shows that the time of PRN medication administration is not always documented. There is a Medication Administration Record (MAR) signed; however, for some dates, the specific times of administration are missing on the PRN record. Inaccurate or missing information regarding medication administration may increase the chance of medication being administered incorrectly and result in adversely affecting the person in care. Submit to Licensing by February 26, 2026, a plan outlining how PRN medications will be accurately documented indicating the time of administration. The plan must include the steps that will be taken to come into compliance as well as what measures will be taken to ensure sustained compliance with legislative requirements.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It is noted that there is no system in place to regularly inspect ceiling tract lifts. The manager advises that if there are concerns with the lifts, then there is a system; however, they are not inspected on a regular basis. Failure to have equipment, such as ceiling tract lifts, regularly inspected and monitored may increase risk of injury to persons in care if the equipment breaks or malfunctions while in use. Submit to Licensing by February 26, 2026, a plan outlining how ceiling tract lifts will be inspected on a regular basis to ensure that they remain in safe, working condition. The plan must include the steps that will be taken to come into compliance as well as what measures will be taken to ensure sustained compliance with legislative requirements.
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
  2. Routine Inspection

    5 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The Licensee does not have a system in place to ensure that persons being admitted to the facility comply with the Province's tuberculosis control programs. During the inspection, persons in care's charts were reviewed and documentation was not present to indicate the Licensee had ensured that admitted persons in care had complied with the tuberculosis control program.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • 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 Licensee does not have a system in place to ensure policies and procedures guide employees in all matters related to care. During the inspection, the policy for Immunization, Influenza and Vaccines was reviewed. Upon this review it was noted that there was nothing to help guide employees in ensuring persons admitted to the facility comply with the Province's tuberculosis control program.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The Licensee does not have a system in place to ensure that written consent to call a medical or nurse practitioner or ambulance in case of accident or illness is obtained and retained. During the inspection, person in care's charts were reviewed and it was noted that there was consent to share information with physicians, but no consent to call a medical or nurse practitioner or ambulance in case of accident or illness.
      • R4.1L - 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)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Licensee's system to ensure each meal contains 3 food groups described in Canada's Food Guide was found to be inefficient. During the inspection, it was noted that some meals on the menu do not contain 3 food groups. For example, some meals were described as soup and crackers with no specifics to type or ingredients in the soup. Other meals indicated leftovers, but with no description of what the leftovers were.
      • R5.1C - Provide for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups described in Canada's Food Guide; 62( 2 )(a)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The Licensee's system to ensure that food is safely stored was found to be ineffective. During the inspection, it was noted that refrigerator temperatures are being recorded on a regular basis; however, the temperatures of the refrigerator varied and were noted to be out of the safe food storage range. Additionally, there was no guidance for employees on what actions to take should an unsafe temperature be noted.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  3. Routine Inspection

    3 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The Licensee does not have a system in place to ensure that persons in care who use restraints have a restraint care plan in place and are regularly monitored while using the restraint. During the inspection, it was noted that bed rails are used at the request of the person in care for fall prevention; however, there was no care plan in place to guide employees in their use. A Health & Safety Plan was requested by the Licensing Officer at the time of the inspection.
      • R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The Licensee's system to ensure that to ensure there is a policy in place to guide employees in all matters relating to care and supervision of persons in care is ineffective. During the inspection, it was noted that the current restraint policy does not guide staff in meeting the legislative requirements regarding restraints. The Licensee's system to ensure that all policies and procedures are followed by staff was found to be ineffective. During the inspection, it was noted that one medication administration record (MAR) had a pharmacy sticker covering a previous medication order. The facility's Medication Administration policy states, "...pharmacy stickers are never applied to the MAR in a way that they cover any information."
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee does not have a system in place to ensure that persons in care have written documentation stating name, facility name and emergency contact information when leaving the facility. During the inspection, it was noted that 2 of the 3 persons in care do not carry documentation on them when they leave the facility.
      • 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 )
  4. Routine Inspection

    4 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): A record indicating each person in care's immunization status must be kept as per section 49(1) of the RCR and the Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care.
      • 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
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): A system of self-monitoring must be implemented to ensure compliance with the Act and Residential Care Regulation (RCR) in accordance with section 61 of the RCR.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): A person must not be employed without the licensee/manager obtaining evidence of/or a written statement of immunization status (to the best of their knowledge). See BC Immunization Schedule.
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): A record indicating each employee's immunization status must be kept as per section 86(c) of the RCR.
      • R4.4C - Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
  5. Routine Inspection

    5 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system for ensuring employees assess and document the effectiveness of PRN medications administered to persons in care on the Medication Administration Record (MAR) is ineffective. LO reviewed the MAR and discussed the findings with the manager. It was identified that employees are not assessing the effectiveness of PRN medications they are administering. There is documentation why the PRN was administered, however there is no documented assessment if it was effective or not. The manager stated he would contact the pharmacist and inquire about an educational in-service for the employees regarding how to assess PRN effectiveness and the importance of documenting.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 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): 1) There is no system in place to advise persons in care and their representatives prior to admission of all charges, fees, and other services offered. Licensing Officer (LO) inquired how persons in care and their representatives are informed prior to admission of all charges, fees, and other services offered. 2) There is no system in place to ensure persons in care and their representatives are advised prior to admission of how to express concerns or make complaints to Licensing. LO discussed this with the manager in reviewing the complaint policy and it was noted the policy directs individuals to bring concerns forward to CLBC, and it does not address how to bring concerns forward to Licensing. 3) There is no system in place to communicate the required information in a manner appropriate to the abilities of the person and their representative. The manager provided a copy of the orientation check list to illustrate the topics that are covered when the person is orientated to the facility, however it is only communicated verbally at time of admission.
      • R2.1A - Advise of all charges/fees/other payments for accommodation/other services offered prior to admission; 48( 1 )(a)
      • R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
      • R2.1E - Communicate required advice in a manner appropriate to the skills and abilities of the person, their parent, or representative; 48 ( 2 )
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system in place to ensure that a short term care plan is developed upon admission and guides caregivers in protecting and promoting health and safety of persons in care is ineffective. LO reviewed a person in care's short term care plan and it did not address individuals leaving the facility independently, how long they can be gone for, the procedure for notifying staff they are leaving the facility, or actions required by the employees should the person not return to the facility by the agreed upon time.
      • R4.1O - Ensure a short term care plan is developed on admission that guides caregivers in protecting and promoting the health and safety of the person in care; 80 ( 1 )
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system to ensure the safe storage of food is ineffective. LO reviewed the daily fridge temperature log and noted that there were several days at a time when the fridge temperature was not monitored or recorded. The manager stated he will change the current system in place and add temperature monitoring to the night staff's job description and he will monitor the documentation daily to ensure it is completed.
      • 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 in place to ensure that hazardous materials are stored safely is in effective. During the physical inspection of the facility LO noted a bottle of hazardous cleaner in an unlocked cupboard under the kitchen sink. The manager removed the item and locked it up during the inspection.
      • 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)
  6. Monitoring

    3 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): UNRESOLVED - The system that is in place for the monitoring of the furniture used by persons in care to ensure it is in a good state if repair is ineffective. The manager stated that following the monitoring inspection last year a patch was applied to the arm of the leather recliner chair to cover the hole that that had stuffing protruding from it. During the inspection it was observed by Licensing Officer that the patch was not in place, and the leather of the chair is heavily worn in multiple areas leaving the surface porous and unable to properly sanitize.
      • R7.2N - Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The facility does not have a policy in place to guide the employees in outbreak prevention or outbreak control.
      • 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)
    • R4.6 - Are facility records current and complete?
      • Observation(s): The facility does not have a process in place to ensure that the monitoring of the food services is documented. The manager stated that the employees prepare the meals for the persons in care, and they also eat with them. The food services are monitored on a daily basis however there is no record of the monitoring that is being done.
      • R4.6D - Retain the results of monitoring of food services and nutrition care; 87(c)
  7. Monitoring

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): January 10, 2017 - The facility does not have a system in place to ensure compliance with reporting reportable incidents to Licensing. Upon discussions with the Manager it was discovered that the facility has not been completing incident reports and submitting them to Licensing when a person in care is involved in a reportable incident.
      • 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)
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): January 10, 2017 - The facility does not have a system in place for ensuring compliance with maintaining all furniture in a good state of repair. The arm of a recliner chair was noted to have a large hole and there was stuffing protruding out of it.
      • R7.2N - Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): January 10, 2017 - The facility does not have a system in place to ensure compliance with employees following facility's policies and procedure for incident reporting. The facility has not been reporting reportable incidents to Licensing.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)