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Orchard Manor at Hawthorn Park

3221 Casorso Rd Kelowna BC V1Y 3J5 · Residential Care - Licensing

11 inspections

  1. Routine Inspection

    4 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The Licensee’s system to ensure persons in care are monitored during the use of a restraint is ineffective. A restraint is being used daily and is in use at the time of inspection, and the person in care’s safety and physical and emotional dignity had not been monitored and/or documented for the preceding 7 days. If the use of a restraint is not monitored and/or documented there is a risk to the health, safety, and or dignity of the person in care. The Licensee will submit a Compliance Plan by May 29, 2026 confirming that the non-compliance with restraint monitoring and/or documenting has been corrected and include the system that will be implemented for ongoing self-monitoring. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The Licensee does not have monitoring systems in place to ensure that the noted non-compliance stated in the body of this report is self-identified by the Licensee. If monitoring is not in place to ensure compliance with the legislation there is increased risk to the health, safety or dignity of persons in care. The Licensee will submit a Compliance Plan by May 29, 2026 confirming that the non-compliance with self-monitoring has been corrected and include the systems that will be implemented for ongoing self-monitoring. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The Licensee does not have a system in place to ensure that hygiene protocol is followed for the use of brushes, combs, and/or razors for persons in care. In two bathrooms it is noted that an unlabeled brush, combs, and razors are being used for persons in care. If hygiene protocol is not followed there is increased risk to the health, safety or dignity of persons in care. The Licensee will submit a Compliance Plan by May 29, 2026 confirming that the non-compliance with hygiene protocol has been corrected and include the system that will be implemented for ongoing self-monitoring. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • 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’s system to ensure that care plans take into account the unique abilities, physical, social and emotional needs, and cultural and spiritual preference of persons in care is ineffective. Three care plans were reviewed, and it is noted that general and/or incorrect directives were in the plans. The Licensee stated that certain electronic care plan entries auto-populate comments that may not apply to the person in care, and that they will look into having this system remedied. When directives on care plans are not specific to the needs of the person in care there is a risk that employees will not provide appropriate care resulting in a risk of poorer outcomes for persons in care. The Licensee will submit a Compliance Plan by May 29, 2026 confirming that the non-compliance with care plan directives has been corrected and include the system that will be implemented for ongoing self-monitoring. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance. The Licensee’s system to ensure that care plans contain all of the legislative requirements is ineffective. Three care plans were reviewed, and it is noted that those with a behavioral care plan(s) did not contain triggers and/or interventions to guide employees. This is a re-occurring contravention previously addressed in the Compliance Plans put in place in response to the November 2, 2022 and October 9, 2024 routine inspections. If triggers and/or interventions are not in place to guide employees in providing care for persons in care with responsive behaviors, there is a risk of poorer outcomes for persons in care experiencing responsive behaviors. The Licensee will submit a Compliance Plan by May 29, 2026 confirming that the non-compliance with responsive behavior care planning has been corrected and include the system that will be implemented for ongoing self-monitoring. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance. The Licensee’s system to ensure that care plans and my days contain the same directives is ineffective. Three care plans were reviewed, and it is noted that approximately seven directives for the three persons in care were contradictory on either the care plan or the my day. When directives on care plans are not current and/or the same there is a risk that employees will not provide appropriate care resulting in a risk of poorer outcomes for persons in care. The Licensee will submit a Compliance Plan by May 29, 2026 confirming that the non-compliance with care plan and my day directives has been corrected and include the system that will be implemented for ongoing self-monitoring. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
      • 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)
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • 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)
  2. Routine Inspection

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): October 9, 2024 The Licensee has a system in place to ensure that reportable incidents are submitted to Licensing. An audit of reportable incident submissions was conducted by the Licensing Officer prior to the inspection, and it was noted that although reportable incidents were submitted in a timely manner, many required follow-up by Licensing due to not containing all of the required information. This is a re-occurring contravention previously addressed in the Compliance Plan put in place in response to the November 2, 2022 routine inspection. The Director of Care reviewed their system with the Licensing Officer and made immediate plans to correct and monitor the system.
      • 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)
    • 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): October 9, 2024 The Licensee does not have a system in place to ensure that all employees are orientated to The Community Care and Assisted Living Act and Residential Care Regulation.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): October 9, 2024 The Licensee does not have a system in place to ensure that the posted menu contains all of the legislative requirements; A licensee must ensure that each menu provides for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide, and for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide. During the inspection it was noted that the posted menu did not include breakfast and snacks.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
    • 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): October 9, 2024 The Licensee’s system to ensure that care plans contain all of the legislative requirements is ineffective. The Licensing Officer reviewed four care plans and noted that those with behavioural care plans did not contain interventions to guide employees. In addition, it was also noted that My Day interventions were not always in alignment with care plan directives. This is a re-occurring contravention previously addressed in the Compliance Plan put in place in response to the November 2, 2022 routine inspection.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
  3. Routine Inspection

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Historically the Licensee has submitted Health and Safety Plans and/or Compliance Plans to ensure compliance with Residential Care Regulation 77(2)(c), and it was noted during the inspection that the plans are ineffective. Multiple Incident Reports were submitted incomplete and/or late in 2022.
      • 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)
    • 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 assessed as a Falls Risk have a Falls Prevention Plan in place. Three Care Plans reviewed stated that persons in care were a Falls Risk however, Fall Prevention Plans were not documented in the Care Plan.
      • R10.4P - 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)
    • 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 observed during the Inspection that chairs were placed at the emergency exits in three locations
      • 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): Water temperature taken in two locations accessible to persons in care exceeded 49 degrees Celsius Hazardous items were noted in the courtyard such as sharp metal panels and potential tripping hazards such as cleaning apparatus It was observed that a service room door was left open with supplies easily accessible ,as well as treatment cream boxes were not locked on cart in hallway.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • 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)
    • 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 have a system in place to ensure that persons in care who have responsive behaviour have a Behavioural intervention plan in place. Two Care Plans reviewed stated that persons in care have responsive behaviour however, Behavioural interventions were not documented in the Care Plan.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
  4. Routine Inspection

    1 infraction

    • 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): August 15, 2019 1.) The Licensee has an emergency preparedness system in place which includes a tablet containing the photos of persons in care for identification purposes, however the evacuation process does not include a directive on what items are to be taken from the facility during an evacuation. 2.) It was noted during the inspection that the facility's procedure binder for emergency preparedness did not include an evacuation site.
      • R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
      • R2.1G - Have a plan that sets out how persons in care will continue to be cared for in the event of an emergency; 51( 1 )(b)
  5. Routine Inspection

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): February 14, 2019 -It was noted that the facility does not have a system in place to ensure that the current manager's name is posted in a prominent place. The manager ensured that a name plate would be in place by the following day or early the following week at the latest. The name plate was ordered during the inspection.
      • 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): February 14, 2019 -It was noted during the inspection that designated outdoor emergency evacuation routes were not cleared of snow. The facility did not have a system in place to ensure that all pathways of the evacuation routes were able to be safely used. The manager spoke with maintenance and had all evacuation routes cleared of snow during the inspection. The manager reported that monitoring of the evacuation routes will be conducted by maintenance during daily audits.
      • R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): February 14, 2019 -It was noted that the system in place to document monthly weights was ineffective. During the inspection it was noted that some persons in care were missing records of monthly weights. The manager reported that a system will be put into place moving forward. Monthly weights will be reviewed with staff during weekly meetings.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): February 14, 2019 -It was noted during the inspection that the facility did not have a system in place to ensure that all persons in care carry written documentation containing identification when they temporarily leave the facility. The manager reported during the inspection that a system will be put into place to ensure that the persons in care will carry identification containing their name, facility name, and emergency contact information. The manager reported that persons in care and family council meetings will be provided two times per year.
      • 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. Monitoring

    5 infractions

    • RB1.9 - Are persons in care able to have family or a representative participate on the resident or family council on their own behalf?
      • Observation(s): Please see report.
      • RB1.9A - Ensure persons in care are able to have family or a representative participate on the resident or family council on their behalf.
    • RB1.10 - 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): Please see report.
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): June 11, 2018 -It was noted that a fridge's contents were accessible to persons in care, and the accessible food may not meet the needs of each person in care's nutrition plan. The manager reported that the facility has been trialing different systems for securing the fridge, however at the time of the inspection the contents were accessible to the persons in care.
      • R5.1E - Provide a variety of foods in consideration of each person in care's nutrition plan and needs; 62( 2 )(c)(i)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): June 11, 2018 -It was noted during the inspection that the facility's system for ensuring that hazardous materials are not accessible to persons in care was ineffective. A sharp knife was accessible to the persons in care. The knife was removed during the inspection. A barbecue propane tank was accessible to the persons in care. The manager reported that monitoring for compliance on the above two infractions will be added to the facility's audits.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): June 11, 2018 -The facility did not have a system in place to ensure that opportunities were offered to persons in care and their representatives to establish a council or to meet as a group to promote the collective and individual interests of the persons in care.
      • R10.2R - 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)
      • R10.2S - Provide at least an annual opportunity for councils, or if no council is established, as a group, to meet with the licensee to promote the collective and individual interests of the persons in care and involve the persons in care in decision making on matters that affect their day to day living; 59(b)(i)(ii) (Show More)
  7. Monitoring

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): January 6, 2017 -It was noted that the facility's system for ensuring compliance with monitoring the physical environment (clearing snow from the patio area which serves as an emergency evacuation route) and care (ensuring that updated care plans are located in all of the areas as per facility procedure) are ineffective.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): January 6, 2017 -It was noted that the facility's system to ensure compliance with the water temperature not exceeding 49 degrees Celsius was ineffective as water temperature measured 51 degrees Celsius in several locations. The manager reported that follow-up with maintenance would occur immediately. -It was noted that the facility's system for ensuring compliance with the safe storage of cleaning agents/hazardous materials was ineffective as a tub room containing hazardous materials was noted to be unlocked at the time of the inspection, and accessible to persons in care. The manager reported that follow-up with staff would occur immediately. -It was noted that the facility's system for ensuring compliance with access to emergency exits was ineffective as the exit ways and patio were not cleared of snow at the time of inspection. The manager reported that follow-up with maintenance would occur immediately.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): January 6, 2017 -It was noted that the facility did not have a system in place to ensure compliance with the regulations for providing ongoing room tray service. The manager reported that this would be followed up on immediately.
      • 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)
  8. Monitoring

    4 infractions

    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): NEW INFRACTION from June 6, 2016 -The facility's process for ensuring physician notification in the event of a reportable incident is ineffective as it was noted in two charts reviewed that the documentation did not indicate if the physician had been notified. The manager reported that the facility will put a system into place to ensure that the physician is notified in the case of all reportable incidents.
      • Immediately notify the medical or nurse practitioner responsible for the person in care involved in a reportable incident; 77( 2 )(b)
    • 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): -The facility's process for ensuring that behaviour care plans are complete was ineffective as it was noted that a PIC with behavioural issues did not have a care plan that included a plan to guide staff in providing care during behavioural episodes such as resistance. -The facility's process for ensuring that nutrition plans are complete was ineffective as it was noted that the care plans reviewed did not contain information regarding the specific nutrition to be provided. -The facility's process for ensuring that the PIC's My Day is posted is ineffective as it was noted that one PIC did not have the My Day (that guides staff in providing care) posted. The manager reported that the PIC takes the My Day down, and that the facility will put a system into place to ensure that the My Day remains posted.
      • 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.
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): NEW INFRACTION from June 6, 2016 -The facility's system for ensuring that PICs are weighed monthly was ineffective as it was noted that one PIC who does not use the bath scale was not being weighed monthly.
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 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): NEW INFRACTIONS from June 6, 2016 -The facility's process for ensuring that behaviour care plans are complete was ineffective as it was noted that a PIC with behavioural issues did not have a care plan that included a plan to guide staff in providing care during behavioural episodes such as resistance. -The facility's process for ensuring that nutrition plans are complete was ineffective as it was noted that the care plans reviewed did not contain information regarding the specific nutrition to be provided. -The facility's process for ensuring that the PIC's My Day is posted is ineffective as it was noted that one PIC did not have the My Day (that guides staff in providing care) posted. The manager reported that the PIC takes the My Day down, and that the facility will put a system into place to ensure that the My Day remains posted.
      • Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)
      • 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
  9. Monitoring

    13 infractions

    • 3.2 Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • 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)
    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): NEW INFRACTION from Jan. 11, 2016 -It was noted that in several instances scheduled medication had not been signed as given.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): NEW INFRACTION from Jan. 11, 2016 -A file search for Orchard Manor indicated that the facility has submitted 29 incident reports in 2015 and 15 (52%) were reported late.
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): NEW INFRACTION from Jan. 11, 2016 -It was noted that 2 lifts required cleaning.
      • Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Jan. 11, 2016 NEW INFRACTION -It was noted that there is an outstanding infraction for no documentation of post antibiotic treatment assessments from the July 30, 2015 inspection. A Health and Safety Plan was put into place by the facility stating that the LPNs would be educated on Aug. 19 and 20, 2015 however on Jan. 11, 2016 it was found that the facility remained out of compliance with this Regulation 50(1).
      • Regularly monitor the physical environment and the care and services provided; 61
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): Please see report.
      • Respect personal privacy and keep records and personal information confidential.
    • 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): OUTSTANDING from March 5, 2015 -It was noted that staff were not following the falls policy at times (It was noted that a post falls check list has been developed since the March 5th inspection and was being followed, however Vital Signs were not documented as per facility policy). OUTSTANDING from June 2014 and July 30, 2015 -It was noted that TAR documentation was incomplete (unable to locate documentation of skin assessments). NEW INFRACTION from Jan. 11, 2016 -It was noted that the emergency plan was outdated (residents had changed) - Corrected during inspection
      • Update emergency plans if there is any change in the facility; 51 ( 2 )
      • 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): NEW INFRACTION from Jan. 11, 2016 -It was noted that the facility had a Health and Safety Plan in place to ensure that post antibiotic treatment assessments were conducted, however upon inspection it was determined that post antibiotic treatment assessment documentation could not be located.
      • 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)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): OUTSTANDING from July 30, 2015 -It was noted that treatment records in one neighbourhood were viewable to passersby. NEW INFRACTION from Jan. 11, 2016 -It was noted that one chart inspected did not contain an admission height and weight.
      • Record the height and weight of each person in care on admission; 49 ( 2 )
      • 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
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): OUTSTANDING from June 2014 -It was noted that fridge temperatures were not recorded consistently in one dining room.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): OUTSTANDING from July 30, 2015 -It was noted that the cord from a music player was accessible to residents and posed a safety risk. NEW INFRACTIONS from Jan. 11, 2016 -It was noted that water was leaking from the ceiling at the entrance to one neighbourhood; a bucket, towel and yellow placards had been placed at the site however water was splashing onto the floor and posed a risk for slipping. -It was noted that hand rails in 2 neighbourhoods required cleaning. -It was noted that a box containing prescription medications was unlocked and accessible to persons in care. -It was noted that an unlocked housekeeping cart was unattended in the hall and hazardous materials were accessible to persons in care.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): OUTSTANDING from July 30, 2015 -It was noted that residents receiving antibiotic treatment did not have documentation indicating that post treatment assessments had been conducted.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 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): NEW INFRACTION from Jan. 11, 2016 -It was noted that one care plan contained the directive; monthly vital signs, however documentation could not be located to indicate that monthly vital signs had been done.
      • 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
  10. Monitoring

    14 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): OUTSTANDING from March 5, 2015; July 30, 2015 - Unable to locate current consent from MRP for the use of a restraint.
      • 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)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): OUTSTANDING from March 5, 2015 July 30, 2015 - Restraint records incomplete.
      • 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 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)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): OUTSTANDING from March 5, 2015 July 30, 2015 - Restraint care plan and documentation noted to be incomplete.
      • Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
      • Provide in the care plan a plan to address, if there is agreement to the use of restraints, the type or nature of restraint and the frequency of reassessment; 81( 3 )(a)(iii)
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): See Report
      • Respect personal privacy and keep records and personal information confidential.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): July 30, 2015 - Licensing did not receive notice of change of manager.
      • 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): OUTSTANDING from March 5, 2015: July 30, 2015 - Noted that staff were not following the falls policy at times. - Noted that PRN medication administration effectiveness was not always documented. OUTSTANDING from June 2014; July 30, 2015 - Inconsistent TAR documentation, including assessment of skin condition and reason for discontinuing treatment.
      • 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): OUTSTANDING from June 2014; July 30, 2015 - It was noted that some staff files are missing performance evaluations.
      • 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): OUTSTANDING from March 5, 2015; July 30, 2015 - Unable to locate consent as per RCR 78(3)(a) July 30, 2015 - New Infraction - Treatment records were viewable to passersby.
      • 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)
      • 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
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): OUTSTANDING from March 5, 2015 July 30, 2015 - It was noted that records of performance reviews were not kept on all staff.
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): OUTSTANDING from March 5, 2015 July 30, 2015 - It was noted that 2 snacks per day were not included in the posted menu.
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): OUTSTANDING from June 2014 July 30, 2015 - It was noted that fridge temperatures were not logged daily for the dining room fridge.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): OUTSTANDING from March 5, 2015 July 30, 2015 - Some resident's rooms noted to have damaged/scuffed walls. July 30, 2015 - New Infraction - Cord from music player accessible to residents and posed a safety risk. - Sharps in an unlocked room and accessible to residents - Corrected During Inspection.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): July 30, 2015 - New Infraction - It was noted that one resident had received antibiotic treatment and documentation indicated that a follow up assessment had not occurred.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 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): OUTSTANDING - from March 5, 2015 July 30, 2015 - It was noted that some oral care plans had not been reviewed within the past year. - It was noted that some nutrition plans had not been reviewed within the past year. July 30, 2015 - New Infraction - It was noted that some "My Days" had not been reviewed/revised within the past 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)
      • 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)
  11. Monitoring

    17 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): 05-Mar-2015-Falls policy found to be incomplete and outdated. 05-Mar-2015 - Unable to locate consent from MRP for the use of a restraint.
      • 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)
      • Written falls prevention policies and procedures are required for assessing risks that may result in a person in care falling including a plan for preventing falls, responding to falls suffered and including care and subsequent prevention(Applies only to Long Term Care); 85(2)(a)(i)(ii)(iii).
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): 05-Mar-2015-Restraint records incomplete
      • 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)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): 05-Mar-2015-It was noted that one reportable incident had not been reported to Licensing
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77(2)(c)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): 05-Mar-2015-Restraint care plan and documentation noted to be incomplete.
      • 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)
      • Ensure all alternatives to the use of a restraint have been considered and either implemented or rejected; 73(2)(a)
      • Train employees in alternatives to the use of restraints. They must be able to determine when alternatives are most appropriate, when to use restraints and how to monitor the use of them; 73(2)(b)(i)
      • Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73(2)c
      • Provide in the care plan a plan to address, if there is agreement to the use of restraints, the type or nature of restraint and the frequency of reassessment; 81(3)(a)(iii)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): 05-Mar-2015-Corrected During Inspection
      • 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)
    • 5 - Are persons in care informed on how to express concerns or make complaints to the medical health officer or to the Patient Care Quality Office prior to admission?
    • 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): 05-Mar-2015 -Corrected during inspection
    • 19 - Are rights of adult persons in care displayed in a form and in the manner acceptable to the minister?
      • Observation(s): 05-Mar-2015 -Corrected during inspection
    • 21 - Are rights of persons in care prominently displayed in the facility?
      • Observation(s): 05-Mar-2015 - Corrected during inspection
    • 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): 05-Mar-2015-It was noted that a policy to guide staff in handling complaints could not be located in the facility - Corrected During Inspection. - Several policies reviewed were found to have not been reviewed within the past year. - Noted that staff were not following the falls policy. - Noted that the facility was not following their policy for water temperature. 05-Mar-2015-It was noted that PRN medication administration effectiveness was not always documented. June 2014 infraction (Inconsistent TAR documentation, including assessment of skin condition and reason for discontinuing treatment) 05-Mar-2015 -This remains OUTSTANDING.
      • Review and, if necessary, revise policies and procedures at least once a year; 85(1)(b)
      • 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): June 2014 infraction - missing performance evaluations - 05-Mar-2015 - this remains OUTSTANDING June 2014 infraction - missing reference checks - 05-Mar-2015-this remains OUTSTANDING - management has a plan in place to place character references in the files of long term employees.
      • Obtain character references for all employed persons; 37(1)(b)
      • 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?
      • 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): 05-Mar-2015-employee records incomplete
      • Keep employee character references; 86(b)
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62(2)( c)(i)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): June 2014 infraction 05-Mar-2015-This remains OUTSTANDING -Noted that fridge temperatures were not logged daily for the dining room fridge, and that when high temperatures were recorded there was no evidence of intervention. The manager reported that a new thermometer would be placed in the dining room fridge, and that the desired range of 0 to 4 degrees Celsius and indication of intervention would be added to the log. 05-Mar-2015-Several unlabeled razors were noted to be in one drawer in a "sink room".
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 (1)
      • Ensure that food is safely prepared, stored, served and handled; 63 (1)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): June 2014 infraction (water temperature) 05-Mar-2015-This remains OUTSTANDING -water temperatures today measured 52.4 and 53.0 degrees Celsius. June 2014 infraction (chipped paint throughout) 05-Mar-2015-This remains OUTSTANDING -some touch ups to paint noted, however there are areas remaining with damaged paint. 05-Mar-2015-One resident's room noted to have damaged/scuffed walls. 05-Mar-2015- Chairs noted to be placed beside an emergency exit. June 2014 infraction (dishwashing liquid accessible to residents in activity room) 05-Mar-2015-dishwashing liquid accessible - corrected during inspection 05-Mar-2015-Knife in activity room and accessible to residents - corrected during inspection
      • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
      • Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 (2)
      • 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)
    • 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): 05-Mar-2015- It was noted that some oral care plans had not been reviewed within the past year. 05-Mar-2015- It was noted that some nutrition plans had not been reviewed within the past 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)
      • 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)