Parkview Place
707 3 Ave Enderby BC V0E 1V0 · Residential Care - Licensing
8 inspections
- Routine Inspection
2 infractions
- R8.2 - Does the program of activities support individualized care plan requirements?
- Observation(s): The program of activities is only available to persons in care for 4 days a week. Currently there are no activities offered on Mondays. This was previously noted as a contravention during the September 2023 inspection. The compliance plan implemented at that time has not been successful.
- 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)
- 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 that a Person in Care did not not have a restraint monitoring flow sheet as required and accordingly restraint monitoring was not being tracked as required. A flow sheet was created and put in place after observation. The facility emergency plan is not displayed in a prominent place.
- R2.1I - Display a copy of the emergency plan in a prominent place; 51 ( 4 )
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R8.2 - Does the program of activities support individualized care plan requirements?
- Routine Inspection
3 infractions
- R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
- Observation(s): While the facility does provide a program of activities, these are only available 4 days a week.
- R8.1A - Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55( 1 )(a)(i)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): No performance reviews have been completed since the last inspection. This is a repeat contravention from December 2022.
- 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)
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): MARs are not being updated by a pharmacist as required. Staff are hand writing new orders directly onto the MAR.
- R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
- R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
- Routine Inspection
5 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The last routine inspection report dated June 2022 was not posted. During the inspection, several items addressed indicate an ineffective system for self-monitoring. For example, a binder for audits was completely empty. This contravention was also noted during the last two routine inspections.
- R1.1O - 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)
- 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): Documentation for assessment of restraints and subsequent charting is being completed at end of shift instead of time of observation as per policy.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Staff performance evaluations are currently overdue, the last of which was completed in April 2022. This contravention was also noted during 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The following deficiencies to the physical facility were observed on the outdoor patio and front area used by persons in care; *Cracks and uneven pavement in the patio area which pose a tripping and falls risk *Snow and Ice not salted, sanded or removed posing a slipping hazard *Covered sheltered area not accessible due to clutter and storage of unsafe material such as unstable cabinets, claw-like gardening tool.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1AN - Provide outside activity areas that have comfortable seating including a reasonable amount of shelter from sun and inclement weather; 36 ( 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): Care plan noted for a person in care included a restraint plan which was not indicated on the "My Day" plan. This contravention was also noted during the last routine inspection.
- 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
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection
6 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Medication Administration Records were observed during this inspection, PRN effectiveness was noted to be sporadically charted.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Licensing reviewed facility progress notes during this inspection, some reportable incidents were observed which were not reported to Licensing. Please review/update incident reporting procedures to ensure reportable incidents are reported to Licensing per Schedule D of the Residential Care Regulation.
- 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)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): During the routine inspection, several items addressed indicate an ineffective process for self-monitoring. This contravention was also noted during the last routine inspection.
- 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): Staff performance evaluations are currently overdue. Facility policy indicates all LPN's have first aid/CPR, currently the system in place to ensure all LPN's have valid first aid/CPR is ineffective.
- 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)
- R3.1O - Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Facility does not have a process in place to document substitutions to the posted menu.
- R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
- 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): Person in care diet change was observed in progress notes, but was not noted in Resident Day or Care Plan. Some restraint charting observed during this inspection was pre-charted, checks later in the day had already been charted. Some charts observed with a "purple dot" indicating a behaviour plan, but the care plan did not include a behaviour plan.
- 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)
- 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
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
4 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): While reviewing a sampling of person in care's Medication Administration Records (MARs), it was noted that several signatures were missing to indicate if the medications were in fact administered.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): During the inspection, several items addressed indicate an ineffective process for self-monitoring / auditing of the care and services provided and ensuring continued compliance to the Residential Care Regulations. Some of the ineffective auditing processes are indicated below: - ensuring that staff who require first aid and CPR have those certifications that are current - ensuring that continuing education of staff is tracked to ensure that all staff are trained and experienced in all aspects of their duties (examples: fire drills, evacuation procedures, mandatory education, etc) - ensuring Wound Treatment records are consistent with the care plan of the person in care and is implemented correctly - ensuring that care plans are reviewed and/or revised with any significant change - ensuring that care plans are consistent with the Resident's Day sheet in the chart and in person in care's bathroom - ensuring that Medication Administration Records (MARs) are completed correctly - ensuring that the physical environment is maintained in a safe and clean condition to ensure the health, safety and dignity of the persons in care.
- 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): During the inspection, it was noted that the front patio (outdoor space) was locked from access for persons in care due to the peeling floor surface and was noted as a tripping hazard by the facility. There is currently no plan in place to have this repaired and re-opened for access to persons in care. Upon inspection of the back patio space, an old rusty paint can with a small opening cut in the metal lid was present, filled 3/4 full with cigarette waste/ash. There is no system in place to clean/maintain this container, nor prevent other persons in care from accessing this container and possibly injuring themselves.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 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): Upon review of a sampling of Wound Treatment records, a few records had missing signatures/documentation to indicate whether the dressing was changed (or treatment applied) as per the wound treatment plan. During review of one person in care's chart, the Resident's Day indicated that a falls mat was to be used, but this was not indicated in the current Care Plan for that individual. This specific care plan was corrected during the inspection by the RN.
- R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
- R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
3 infractions
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): The system in place to ensure restraint care plans are appropriate is ineffective. It was noted during the inspection a restraint was in use without documentation in the care plan of a person in care.
- 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
- R10.4O - 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): It was noted during the inspection large icicles were hanging from the roof of building above the sidewalk of the facility. The icicles were cleared from above the walkway during the inspection. It was noted during the inspection the menu was displayed on the fridge in the kitchen. The menu was removed from the fridge in the kitchen and posted on the communication board in the dining room during the inspection.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): The system in place for monitoring medications is ineffective. It was noted during the inspection a prescribed treatment was given twice a day when the order was to be given only once a day.
- R9.1E - Administer only medications prescribed or ordered by the medical or nurse practitioner; 70 ( 1 )
- R10.4 - Are restraint and fall prevention plans appropriate?
- Monitoring
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 compliance with accurate and complete medication administration records is ineffective. Missing signatures were noted on several regularly scheduled medications on several Medication Administration Records. This was noted on the previous inspection report and remains outstanding. Missing signatures were noted on several regularly scheduled treatments on the Treatment Administration Record. This was noted on the previous inspection report and remains outstanding. The Program Manager set forth an action plan during the inspection of which audits will take place on a daily basis for two weeks with immediate follow up to address this issue daily. There is also a nursing meeting scheduled for today of which these infraction will be discussed.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): The system in place for ensuring the the monitoring the person in care during the use of restraints is ineffective. Several missed entries were noted on the restraint monitoring sheet on two persons in care. This was noted on the previous inspection report and remains outstanding. The Program Manager set forth an action plan during the inspection of which audits will take place on a daily basis for two weeks with immediate follow up to address this issue daily. There is also a nursing meeting scheduled for today of which this infraction will be discussed.
- 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)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): The system for ensuring compliance with the policy on the effectiveness of monitoring as needed medications is ineffective. The effectiveness on several as needed medications was not documented on the Medication Administration record. This was noted on the previous inspection report and remains outstanding. The Program Manager set forth an action plan during the inspection of which audits will take place on a daily basis for two weeks with immediate follow up to address this issue daily. There is also a nursing meeting scheduled for today of which this infraction will be discussed.
- 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): The system for ensuring compliance with records and reporting is ineffective. It was noted that several identifiers such as hair color and height were missing from several person in care records.
- R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The bathing room was found unlocked with cleaning supplies found in an unlocked cupboard accessible to persons in care. The infraction was discussed with a staff member during the inspection and this infraction was corrected 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)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
6 infractions
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Several missed signatures were noted on the Medication Administration Record for regularly scheduled medications. Several missed signatures were noted on the Treatment Administration record for regularly scheduled treatments.
- Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
- Observation(s): Incomplete Immunization and tuberculosis screening was noted on the staffing spreadsheet.
- Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
- 10.4 Are restraint and fall prevention plans appropriate?
- Observation(s): There were several missed entries of restraint monitoring on the monitoring sheet. There was a course of 3 days missed and inaccurate monitoring noted on the restraint monitoring sheet. The frequency of restraint reassessments were not documented on the care plan. Restraint reassessments are taking place every two months. The reassessment frequency was added to the care plan during the inspection. This specific infraction was corrected during inspection. (CDI)
- 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)
- 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)
- 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): The emergency preparedness binder still contained the name and emergency hone numbers of the past Administrator. The effectiveness of as needed (PRN) medication was not always documented on the Medication Administration Record.
- 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): The staffing spreadsheet indicated that there was only performance evaluations completed on two staff. The remainder of the staff are yet to be completed.
- 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)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Prescription treatments found accessible in two persons in care bathrooms.
- Ensure all medications are safely and securely stored; 69( 3 )(a)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?