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Orchard Haven

700 3 St Keremeos BC V0X 1N0 · Residential Care - Licensing

11 inspections

  1. Routine Inspection

    1 infraction

    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Observed Care plan for a person in care with an elopement risk which is not updated to reflect most current elopement risk details. If Care Plans are not updated to reflect persons in care's current needs and risks , this can cause potential risk of harm to persons in care . Please submit a corrective action plan by April 23, 2026, advising how all current and future Care Plans will be monitored to ensure are revised and updated as needed to reflect current needs and risks.
      • R10.3G - Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
  2. Routine Inspection

    5 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): 3 restraint agreements were reviewed, 2 of which were not reassessed as per the agreed upon date. Not reassessing a restraint agreement by the agreed upon date can increase the risk of a restraint being unnecessarily used. Submit an action plan by August 5, 2025, outlining how restraint reassessments will be conducted as per the Regulation, including how site leadership will monitor the plan for its effectiveness.
      • R10.4N - Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Contraventions under 85(1)(d), 75(3), and 35(1)(c) were noted during the previous licensing inspection on April 30, 2024, and were again noted during this inspection as non-compliance. There were also multiple incidents of non-compliance under 85(1)(d) and multiple physical contraventions indicating the monitoring systems were ineffective. Submit an action plan by August 5, 2025, outlining how the Licensee will monitor the physical environment and the mentioned services provided, including how site leadership will monitor the plan for its effectiveness.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • 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): PRN medication or take as required medications were not properly charted as per the policy and procedure. One chart showed 6/13 medication administrations improperly charted, another showed 5/8 that were improperly charted. If the PRN medications are not properly charted for effectiveness, this can increase the risk of incorrect dosages, amounts, and medications used to properly manage medical conditions or symptoms. Submit an action plan by August 5, 2025, outlining how staff will document and monitor the PRN medication effectiveness, including how site leadership will monitor the plan for its effectiveness. Admission Separation forms were not completed as per policies/procedures. Licensing Officer reviewed 6 charts, 2 of which were not completed, 2 were not included in the chart, and 2 were completed. Maintaining consistent records as per the policies and procedures ensures appropriate information is collected and stored for persons in care. Submit an action plan by August 5, 2025, outlining how the Licensee will ensure the policies and procedures are followed, including how site leadership will monitor the plan for its effectiveness. A tub room contained 2 unlabeled razors and unlabeled barrier creams. Unlabeled razors and creams increase the risk of the items being used by multiple persons in care, therefore increasing the risk of exposure between persons in care. Submit an action plan by August 5, 2025, outlining how staff will follow the policies and procedures in regards to personal hygiene items in the tub rooms, including how site leadership will monitor the plan for its effectiveness. Licensing observed food items that were brought into the facility by the public without following the policies/procedures, including proper storage. Having food items that are accessible to all persons in care can increase the risk of choking or a person in care ingesting an item causing an allergic reaction. Submit an action plan by August 5, 2025, outlining how the Licensee will ensure outside food items are brought into the facility as per the policy/procedures, including how site leadership will monitor the plan for its effectiveness. A nursing station half-door was left opened contrary to policies/procedures. Leaving the door open increases the risk of persons accessing confidential documents, including person in care's charts. Submit an action plan by August 5, 2025, outlining how the Licensee will ensure the nursing station doors are closed as per policies and procedures, including how site leadership will monitor the plan for its effectiveness.
      • 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): Licensing tested the water temperature for 2 sinks that were accessible to persons in care which were both over 49 degrees, including one sink that was measured at 55 degrees Celsius. Ensuring water temperature does not exceed 49 degrees Celsius reduces the risk of burns to persons in care. Submit an action plan by August 5, 2025, outlining how water temperatures will not exceed 49 degrees Celsius, including how site leadership will monitor the plan for its effectiveness. A medication cart was left unlocked and unattended which allowed for the Licensing Officer to freely access its contents. Medications not being safely and securely stored increases the risk of persons in care accessing and possibly ingesting medications in an uncontrolled manner. Submit an action plan by August 5, 2025, outlining how medications will be safely and securely stored, including how site leadership will monitor the plan for its effectiveness. A dining area contained an unattended broom and dustpan accessible to persons in care. The same dining area contained a cupboard with heavy glass dishes and wheelchair pedals that were accessible to persons in care. Items accessible to persons in care of this nature increases the risk them being used for unintended purposes, such as a tripping hazard or weapon. The glass items were heavy and could also be dropped onto persons in care or on to the floor causing a broken glass issue. Submit an action plan by August 5, 2025, outlining how hazardous items will be properly stored, including how site leadership will monitor the plan for its effectiveness.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • 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)
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Multiple charts were reviewed containing outdated care plans. If care plans are outdated, the risk of staff implementing outdated care increases. Submit an action plan by August 5, 2025, outlining how the Licensee will ensure care plans are current, ensuring staff are implementing the correct care, including how site leadership will monitor the plan for its effectiveness.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  3. Routine Inspection

    4 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Licensing Officer observed a restraint agreement which was not reassessed as required.
      • R10.4N - Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(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): Licensing Officer observed four charts for persons in care, three of which contained an incomplete Admission Assessments Checklist, contrary to facility policy. Licensing Officer Observed Medication Administration Records for four persons in care. One month was missing the documented effectiveness for 3 of 9 pro re nata (PRN) medications, one month was missing the effectiveness for 7 of 20 PRN medications, and another month was missing the effectiveness for 3 of 4 PRN medications, all of which are contrary to facility policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing Officer observed a freezer which contained items for persons in care where its temperature was not being monitored.
      • 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): Licensing Officer observed a linen cart accessible to persons in care, containing razor blades which were not secure, safe, or adequately stored.
      • 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)
  4. Routine Inspection

    7 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Licensing Officer observed a care plan with a restraint but no restraint agreement.
      • 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)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Licensing Officer observed a care plan that included a restraint but did not have any documented alternatives that were considered, implemented, or rejected. Licensing Officer observed a care plan that included a restraint but it did not include a reassessment date.
      • R10.4D - Ensure all alternatives to the use of a restraint have been considered and either implemented or rejected; 73( 2 )(a)
      • R10.4N - Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing Officer observed the licence to not be prominently displayed.
      • R1.1N - Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
    • 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): Licensing Officer observed that there was no formal process to receive complaints. Licensing Officer observed incomplete documents, including; admission/separation forms, admission assessment checklists, a leisure interest and assessment survey, and a resident data/contact form. This was all contrary to facility policy.
      • R2.1J - Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(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): Licensing Officer observed three person in care's charts. One was missing the height on admission, another was missing the weight on admission. Licensing Officer observed three person in care's charts, each was missing previously recorded monthly weights.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • 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): Licensing Officer observed the temperature not being monitored for a fridge, two freezers, and there wasn't weekend monitoring on an additional fridge.
      • 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): Licensing Officer observed the weekly menu not prominently displayed in a specific dining area.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
  5. Routine Inspection

    6 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Licensing Officer reviewed 3 charts of persons in care, all of which did not contain the necessary documentation to comply with the Province's immunization programs.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): Licensing Officer observed glassware that was stored where it was accessible to persons in care.
      • R7.2M - Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Licensing Officer observed a restraint care plan which did not contain a reassessment date.
      • R10.4N - Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(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): Licensing Officer (LO) observed 3 charts for persons in care. LO found that the effectiveness for pro re nata (PRN) medications was not consistently charted. LO also observed chart audit and admission checklist forms not completed in persons in care's charts, which is contrary to facility policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing Officer observed a refrigerator that stored items for persons in care where the temperature was not being monitored.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Licensing Officer observed that persons in care do not carry the necessary documentation with them when leaving 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 )
  6. Routine Inspection

    2 infractions

    • RB1.19 - Are rights of adult persons in care displayed in a form and in the manner acceptable to the minister?
      • Observation(s): See question R1.1 that has been noted on this report.
      • RB1.19A - Display the rights of adult persons in care in a form and manner acceptable to the minister.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The Residents' Bill of Rights could not be located in a prominent place.
      • R1.1Y - Display the rights of adult persons in care in a prominent place and in a form acceptable to the minister; Act 7( 1 )(c.1)(i)(ii)
  7. 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 manager reports that employees have been requested to not take their breaks from 2-3 pm. In addition, a previous plan provided to licensing included the provision for a program of activities during this time period. This direction has not been maintained or monitored.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Self monitoring/oversight practices are inconsistent as they relate to the care and services provided by the licensee. This was observed in the areas of expected staffing levels, availability of recreation activities, and actions to respond to and mitigate responsive behaviours.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • 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 reported by a staff that there is no employee policy for this type of event to guide staff after hours. In addition the facility did not conduct an internal review due to a potential conflict of interest.
      • 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): - Persons in care do not want other persons to access their bedroom. The actions and requests for privacy do not include any physical methods to help meet these needs. - It was identified that there was a delay in obtaining behavioural and psychiatry assessments.
      • R10.2F - Ensure respect for personal privacy of each person in care, including privacy of each person’s bedroom, belongings and storage area; 53
      • R10.2G - Assist persons in care to obtain health services as required and ensure that a medical or nurse practitioner can be contacted in an emergency;54( 2 )(a),54( 2 )(b)
  8. Routine Inspection

    7 infractions

    • R8.2 - Does the program of activities support individualized care plan requirements?
      • Observation(s): A sample audit of five care plans identified that an ongoing planned program of activities does not meet the objectives. Activity care plans are not current or updated during case conferences and do not include the level of participation.
      • R8.2A - 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)
    • RB1.13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): See earlier comments related to an ongoing planned program of activities- Section 55(1)
      • RB1.13A - Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): After some searching, the facility licence was located at the main reception area in a standing frame that was facing the back wall.
      • R1.1N - Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
    • 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 manager reports that new employees do not receive orientation to the regulations and the Act. The employee orientation checklist viewed today does not appear to include this type of direction.
      • R2.1T - 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): - Health care employees receive regular performance reviews. It is reported that other employees do not receive these reviews. - The effectiveness of PRN's is not consistently recorded. This is a repeat contravention from the last routine inspection.
      • 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)
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Required nutritional care needs were not followed for six days after admission. Provide a system for ensuring the nutritional needs and plans are met.
      • R5.1S - 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 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): - Person in care records are missing documentation such as showing how injuries, wounds, and significant changes to eating patterns were managed and resolved. - Person in care records do not contain evidence that dental services have been offered or obtained.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • R10.2J - Assist persons in care to obtain professional dental services as required; 54( 3 )(b)(ii)
  9. Monitoring

    4 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Upon review of a person in care's care plan and charting, the Licensing Officer was unable to locate a written agreement for the use of a restraint.
      • 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): Upon review of multiple person in care's medication administration records, the reason and effectiveness for PRN (as needed) medication administration is not being recorded consistently.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): It was observed that two oxygen concentrators which are used by two persons in care during meals, are stored near the tables in the smaller dining room area. At the time of inspection, they were not in use by the persons in care; however they were still positioned by the tables resulting in the cords being stretched from the electrical outlet to the tables which poses a potential tripping hazard.
      • R7.2M - Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The hot water temperature was tested in the public washroom and in a person in care's room at the time of visit, both of which measured 53 degrees Celsius.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
  10. Monitoring

    3 infractions

    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): It was noted that care plans for persons in care are in need of monitoring and review in order for the Licensee to ensure the person in care's needs are being met. Multiple person in care's care plans identify specific intervals for behaviour reassessment ("purple dot"); however, no evidence is present to indicate reviews are being completed as directed by the facility policies/procedures.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): One person in care has been permitted to bring a large amount of personal items to the facility to keep in their room. These items are stored in a manner that may not be safe to the person in care, staff, or other persons in care who may enter the room; for example, there are boxes and a coffee table piled on top of each other on top of the clothing wardrobe. In addition, there is a wooden shelving unit that is unstable (easily could be knocked or pulled over) which has small appliances, electronics, and smaller items stored on it. When discussing these concerns with the Manager, she stated that she and the staff will discuss the concerns with the person in care and develop a plan on how to make this room safer and more organized. In one person in care's room, the Licensing Officer discovered multiple hazardous items located in the bed side dresser drawers (sharp butcher-style knives, butane lighters, sharp potato peeler). It was also observed on a shelving unit in this room there was canned food (tuna) that had passed the best before date (Aug. 22, 2015). Prior to the end of the first day of inspection, the staff had removed these items from the room. (CDI)
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): A bottle of Vitamin C observed to be accessible to persons in care (on the counter of one person in care's bathroom). Staff removed this prior to the end of the first day of inspection. A licensee must ensure that all medications in the community care facility are safely and securely stored; 69(3)
  11. Monitoring

    6 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Feb 26, 2014 - unable to locate assessments and effectiveness documentation of the PRN treatments applied by the RCA's. Sept 19, 2014 - UNRESOLVED- May 08, 2015 - UNRESOLVED - There continues to be no assessments documented in the Resident's nursing notes indicating why a PRN creams are started and stopped.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78(2)(b)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Sept 19, 2014 - LO was unable to locate character references and copies of diplomas or certificates in some of the staff files. May 08, 2015 - UNRESOLVED - LO unable to access staff files as they are stored in the Manager's office.
      • Obtain character references for all employed persons; 37(1)(b)
      • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37(1)(d)
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): Sept 19, 2014 - Several staff files continue to not contain character reference checks. May 08, 2015 - UNRESOLVED - Unable to assess as staff files stored in Manager's office.
      • Keep employee character references; 86(b)
    • 4.6 Are facility records current and complete?
      • Observation(s): September 19, 2014 - The facility is not documenting their response to the concerns or complaints that are brought forward. May 08, 2015- UNRESOLVED - Unable to assess as the Manager was away and staff report it is kept in her office.
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 (3)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): February 26, 2014 - There are Resident's who have personal fridges in their rooms. the temperatures of these fridges are not monitored nor is the food in them monitored for expiration dates. Sept 19, 2014 - UNRESOLVED - Each resident who has a personal fridge in their room has a managed risk agreement in place, however the fridges continue to not be monitored for safe temperatures and expired food. May 08, 2015 - UNRESOLVED - There is only 1 resident who has a fridge in their room. The Resident is currently responsible for the monitoring of the temperature and food located in the fridge. However the resident is not consistently documenting the temperature or monitoring the food in the fridge.
      • Ensure that food is safely prepared, stored, served and handled; 63 (3)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): May 08, 2015 - The 4 week menu was posted however it was on a different week in 2 different dinning areas.
      • Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 (6)