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Piccadilly Care Center

821 10 Ave SW Salmon Arm BC V1E 1T2 · Residential Care - Licensing

Official record from Interior Health →

Inspection summary

Piccadilly Care Center has been inspected 14 times by Interior Health Authority since March 19, 2015. The most recent inspection, on September 25, 2026, recorded 1 infraction.

1 of 14 inspections on record found no infractions at all. In the past 12 months there were 2 inspections with 6 infractions recorded. All recorded findings relate to upkeep, equipment or paperwork rather than direct health risks.

The number of infractions per inspection has stayed roughly the same over time.

What these findings mean

Health authorities word their findings differently, so we group them by what they mean for the people in care. Higher-risk findings are the ones that could directly make someone sick, and they matter more here because young children, older adults and people who are unwell are more vulnerable to infection.

  • Permits, records and postingLower risk

    Operating permits, required signage, written procedures and logs. These findings are administrative: the documentation was missing or out of date at the time of inspection.

    Recorded 26 times across 13 separate inspections, most recently on September 25, 2026. For example: 5 - Are incidents and notifications reported and records retained as required?

  • Equipment and utensilsLower risk

    Equipment has to be made of cleanable materials, kept in good repair and stored properly. These findings are mostly about upkeep, like a cracked surface or worn part. They are generally lower risk but show how well the place is maintained.

    Recorded 7 times across 7 separate inspections, most recently on September 3, 2026. For example: 1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?

  • Food safety training and certificationLower risk

    Many jurisdictions require a trained or certified person on site, such as a certified food handler. These findings mean the training record or the trained person was missing at the time. They do not by themselves mean anything was handled unsafely.

    Recorded once on November 4, 2016. For example: RB1.22 - Is personal privacy respected and records and personal information kept confidential?

  • Other findingsLower risk

    Findings that do not fit the categories above, such as follow-ups that confirm an earlier violation was corrected, or requirements specific to this type of facility.

    Recorded 17 times across 9 separate inspections, most recently on September 3, 2026. For example: 2 - Is the environment maintained to prevent falls?

About this data

These results come from Interior Health Authority, which inspects food premises and other public facilities in this area. We republish the authority's public disclosure data and refresh it regularly; the official record is the final word.

14 inspections

  1. Routine Inspection Follow-up

    1 infraction

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): During the routine inspection conducted on September 3, 2026, incident reporting requirements related to Residential Care Regulation (RCR) s. 77 and Schedule D were discussed with facility leadership. On September 10, 2026, Licensing was notified of a reportable incident which occurred on September 5, 2026. Licensing was not notified immediately that a person in care (PIC) was involved in a reportable incident, as required. Without immediately notifying Licensing when PICs are involved in reportable incidents, there is risk to the Licensee of non-compliance with legislative standards, and increases risk to the health, safety, and dignity of PICs. Submit by October 9, 2026, a written plan outlining how the medical health officer (Licensing), will be immediately notified, in the form and in the manner required, if a person in care is involved in a reportable incident. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of RCR s. 77(2)(c), thereby ensuring sustained compliance moving forward.
      • R4.5G - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
  2. Routine Inspection

    5 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): A review of restraint documentation, for one person in care (PIC), reveals that the agreement to the use of a restraint given in writing by the representative of the PIC is missing. Without agreements to the use of restraints given in writing there is potential for restraints to be used in error. Submit by September 23, 2026, evidence that for all persons in care who use restraints, restraint documentation is completed.
      • 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)
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): A review of fridge and freezer temperature documentation for the month of August and September, 2026, reveals one freezer temperature out of range with no corrective action documented. **This is a repeated contravention. Corrective actions that are not completed for out of range fridge and freezer temperatures increases risk to PICs as the fridges and freezers are not maintained in a safe condition to store food for PICs. Submit by September 23, 2026, evidence that for all fridges and freezers that contain food for consumption by PICs, where temperatures fall out of range, corrective actions are completed and documented. ___________________________________________________________ A review of furniture and equipment for use by PICs reveals a sharp, broken piece of laminate countertop in a kitchenette accessible to PICs. Facility leadership reports maintenance staff applied a band of tape to the area to mitigate immediate risk of injury to PICs. When furniture and equipment for use by PICs is not maintained in a safe and clean condition, it increases risk of injury to PICs. Submit by September 23, 2026, evidence that all furniture and equipment for use by PICs is maintained in a safe and clean condition.
      • R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): A review of restraint monitoring documentation for one PIC reveals several instances of care planned hourly restraint monitoring documentation recorded outside of the required timeframe. **This is a repeated contravention. The use of a restraint without assessment and monitoring puts PIC's safety and physical and emotional dignity at risk. Submit by September 23, 2026, evidence that for all PICs requiring a restraint, restraint monitoring documentation is recorded within the required timeframe.
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): An item of food for personal consumption by one PIC, stored in one unit's kitchen fridge, is past the best before date. Item removed and discarded by staff. **This is a repeated contravention. Food items past the best before date pose a risk of foodborne illness if consumed by PICs. Submit by September 23, 2026, evidence that food and drink for persons in care is safely prepared, stored, served, and handled.
      • 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): In several areas where water is accessible to PICs (PIC's bedrooms and kitchens), water temperatures are heated to approximately 53 to 56 degrees Celsius. A review of kitchen areas reveal dishwashers that are accessible to PICs, have water temperatures heated to approximately 66 degrees Celsius. A Health and Safety Plan (HSP) is required to ensure that increased risk to PICs is mitigated. Facility HSP: Leadership staff turn power off to dishwashers, care staff monitor areas until dishwasher temperatures decrease to below 49 degrees Celsius, and safety locks to be purchased and installed during inspection. When water accessible to PICs is heated to more than 49 degrees Celsius, PICs are at risk of scalding. Submit by September 23, 2026, evidence that water accessible to PICs, from any source, is not heated to more than 49 degrees Celsius. __________________________________________________________ A review of PIC's bedrooms reveals a roof leak within one PIC's bedroom, where this bedroom is accessible to PICs. Located within the room is a puddle of water on the floor, a ladder, a battery powered hand tool (drill), and a disconnected ceiling light fixture. A HSP is required to ensure that increased risk to PICs is mitigated. Facility HSP: Leadership staff lock and close PIC's bedroom door ensuring inaccessibility to PICs while repairs are being completed. PIC has access to a vacant bedroom, ensuring their health, safety, and dignity. When rooms and common areas are not maintained in a safe and clean condition, it increases risk to PICs health, safety, and dignity. Submit by September 23, 2026, evidence that rooms and common areas are maintained in a safe and clean condition. __________________________________________________________ A review of rooms and common areas accessible to PICs reveals a disposable shaving razor located on a PIC's bathroom countertop, and an unlocked cupboard in one kitchen containing a large knife. **Corrected during inspection. When hazardous materials are not safely and securely stored, it increases risk of laceration injury. Submit by September 23, 2026, evidence that hazardous materials are safely and securely stored.
      • 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)
  3. Routine Inspection

    6 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): On a review of fridge and freezer temperature documentation for the months of July and August 2025, there were 20 fridge temperatures out-of-range with 1 corrective action documented, and 127 freezer temperatures out of range with 0 corrective actions documented. Corrective actions that are not completed for out-of-range fridge and freezer temperatures increases risk to persons in care as the fridges and freezers are not maintained in a safe condition to store food for persons in care. Submit by September 17, 2025, evidence that for all fridges and freezers, where temperatures fall out-of-range, corrective actions are completed and documented.
      • R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): During a review of restraint documentation for one person in care, it was observed that several instances of care planned hourly restraint monitoring documentation were recorded outside of the required timeframe. The use of a restraint without assessment and monitoring puts persons in care's safety and physical and emotional dignity at risk. Submit by September 17, 2025, evidence that for all persons in care requiring a restraint, restraint monitoring documentation is recorded within the required timeframe.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): It was observed that a binder and a tablet (without a passcode), both containing persons in care's personal information, were accessible to persons not privileged to this information. These items were relocated to secure locations during inspection. Persons in care's records and personal information that is not kept confidential poses the risk of breach of confidentiality. Submit by September 17, 2025, evidence that all persons in care's records and personal information are kept confidential.
      • R4.1V - 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
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): It was observed that there was a carton of expired milk in one fridge, and an undated food item in another fridge. These items were disposed of during inspection. Expired and undated food and drink items pose a risk of foodborne illness if consumed by persons in care. Submit by September 17, 2025, evidence that food and drink items are safely prepared, stored, served, and handled.
      • 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): It was observed that two neighbourhood washing machines contained significant build-up of light and dark brown residue in the rubber seal area of the machines. Exposure to residue build-up in washing machines, which may contain bacteria, increases risk of illness to persons in care. Submit by September 17, 2025, evidence that all neighbourhood washing machines are maintained on a regular basis.
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 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): During a review of hourly safety checks for one person in care, it was observed that several instances of care planned hourly safety checks were not documented. The absence of documented safety checks does not allow for confirmation that safety checks are completed which puts persons in care's safety and physical and emotional dignity at risk. Submit by September 17, 2025, evidence that for all persons in care requiring hourly safety checks, safety check documentation is recorded within the required timeframe.
      • 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
  4. Routine Inspection

    4 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): The system to ensure that equipment for use by persons in care is maintained in a safe and clean condition is ineffective. An unlabelled nail clipper was observed on a counter in a main floor tub room. All other nail clippers were kept separated, in labeled drawers, for personal use.
      • R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • 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 to ensure that policies are implemented by employees is ineffective, in relation to mandatory continuing education. It was reported by facility leadership that continuing education has not been completed by each employee on a quarterly basis, as required by facility 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): The system to ensure that employees comply with the policies and procedures of the medication safety and advisory committee is ineffective. A review of temperature documentation for two medication fridges identified temperatures that were out of prescribed range and no evidence of follow up actions to correct this.
      • R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system to ensure secure, safe and adequate storage areas for cleaning agents and chemical products, is ineffective. Cleaning agents were observed in unlocked kitchen cupboards, in two neighbourhoods, accessible to persons in care.
      • 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)
  5. Substantiated complaint

    2 infractions

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Concerns were expressed about the cleanliness of washing machines and dryers. The neighbourhood washing machines had significant mildew and build-up in the rubber seal area of the machines, indicating a lack of ongoing maintenance. Concerns were expressed that staff were smoking at the facility. Evidence of smoking (smoking material disposal container) was noted on the south patio table upon inspection.
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
      • R7.1M - Ensure that no one other than a person in care engages in a restricted activity while on the premises of the facility; 23(2)(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): Concerns were expressed that a person in care was not being provided any recreation opportunities. While the facility provides recreation programming, recreation participation by persons in care is not being consistently recorded.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  6. Routine Inspection

    0 infractions

  7. Routine Inspection

    5 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): Licensing reviewed restraint records for the one person in care with a restraint. Records providing evidence of monitoring were inconsistently completed by employees. This is a reoccurring contravention from March 2021.
      • R4.3D - 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)
    • 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): There is no system in place to advise persons in care or their representatives how to express concerns or make complaints to Licensing.
      • R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): -Licensing reviewed records for newly hired employees. Employee records did not contain evidence of compliance with the province's immunization program, specifically COVID-19 vaccination. This is a reoccurring contravention from March 2022. -Employees receive orientation upon hire, however, evidence of employee's completion of the orientation is not retained on file. -Licensing was unable to review employee records, for hires prior to July 2022, as the previous care provider appropriated records when their contract ended. The Licensee has not obtained any records for employees since this occurred July 2022.
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
      • R3.1L - Ensure employees have the necessary training and experience or demonstrate the necessary competence to carry out duties; 40 ( 3 )
      • R3.1AA - Keep in the case of employees, all records required under section 37 ( 1 )[character and skill requirements] for the entire time that the subject of the records is an employee; 92( 3 )(a)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing reviewed person in care's records. The recording of person in care's weights monthly was inconsistent. The system in place to weight each person in care monthly is ineffective.
      • 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)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Licensing reviewed person in care's care plans. One person in care did not have a wound care plan, however, wound assessment and monitoring documents were completed. The system in place to modify care plans when there is a substantial change in status is ineffective. This is a reoccurring contravention from July 2021, December 2021 and March 2022.
      • 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)
  8. Routine Inspection

    5 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The system in place to document restraint monitoring is ineffective. Restraint monitoring is inconsistently documented.
      • R4.3D - 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The system in place for monitoring the care and services provided is ineffective. This is evident by the number of new and reoccurring contraventions noted in this report. This is a reoccurring contravention from the July 26, 2021.
      • 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): Licensing reviewed a sample of facility policies and procedures. Of this sample numerous have not been reviewed/revised since 2017. This is a reoccurring contravention from the April 26, 2019. Facility policies for wound care assessments, restraint re-assessment and monitoring are inconsistently followed by employees.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • 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): Licensing reviewed a sample of employee records. Character references, work history, criminal record checks (CRC) and current first aid certification were noted as consistently missing from records. -The facility has conducted a thorough review and has confirmed persons in care always have access to at least one employee with first aid certification 24 hours a day. -All LPN/RN employees have valid CRCs. Over half of the active RCA's criminal record checks expired in 2021, require a CRC Share with 3 employees CRC status unknown. A Health & Safety Plan is in place to address this contravention. Performance evaluations for Provita employees have not been conducted regularly. Evaluations for Parkplace have been completed regularly with one outstanding. The Management Team for WestCana was unavailable during the inspection.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • R3.1C - Obtain character references for all employed persons; 37( 1 )(b)
      • R3.1D - Obtain a record of work history for all employed persons; 37( 1 )(c)
      • 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)
    • 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 system in place to monitor the wound care plan is ineffective. Documentation of assessment and treatment is inconsistent. A new system has been developed and is in process of being implemented. This is a reoccurring contravention from December 31, 2021. Care conferences to review and modify care plans when there is a substantial change in the circumstance of the person in care or annually have not been completed. A plan is in place to ensure care conferences are scheduled. At the time of this inspection approximately 25% have been completed. This is a reoccurring contravention from July 26, 2021 and December 31, 2021. Behaviour care plans have recently been revised to include triggers and specific interventions. The Dietician regularly reviews and revises nutrition plans as required.
      • 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)
  9. Substantiated complaint

    2 infractions

    • 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 complainant alleged that concerns communicated to the facility regarding a person in care were not responded to sufficiently. Licensing reviewed the facilities complaint process and noted that concerns received were not followed up on in a timely manner. RCR Section 60(c) is substantiated. The complainant expressed concern that belongings of a person in care regularly go missing. Licensing reviewed facility documents and confirmed that there is a system in place to track personal valuables and guidelines are in place to track items that are reported missing. RCR Section 85(1)(a) is unsubstantiated.
      • R2.1L - Respond to all complaints, concerns, disputes promptly. 60(c)
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
    • 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 complainant alleged that healthcare needs of a person in care are not met. Licensing reviewed the care plan of the person in care. The system in place to verify the wound care plan is followed as indicated appears to be ineffective. Daily treatment is not documented as completed everyday. The facility has a process in place to assess wounds weekly, however this review and any notes regarding effectiveness of treatment is inconsistently completed. RCR Section 81(4)(a) is substantiated. A toileting care plan was not modified as required when there was a significant change in circumstance. RCR Section 81(4)(b)(i)(ii) is substantiated. RCR Section 81(4)(b)(i)(ii) is a reoccurring contravention, last found out of compliance July 2021.
      • 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)
  10. Routine Inspection

    2 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): During the inspection, it was noted that the name of the manager was not posted. This was corrected during the inspection (CDI) and prominently displayed at the main entrance. Upon inspection, it was noted that the last routine inspection record was not posted. This was corrected during the inspection (CDI) and prominently displayed on the community board in the lobby.
      • 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)
      • 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)
    • 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): Upon review of a sampling of policies and procedures, it was noted that half of the reviewed policies and procedures were last reviewed/revised in 2017.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
  11. Monitoring

    5 infractions

    • R6.1 - Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The system for ensuring compliance with immunization screening for staff is ineffective. The immunization screening document was noted to be missing from several staff records.
      • R6.1A - Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • RB1.18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): As previously mentioned in the inspection report - The system for ensuring persons in care are in possession of identification on them when on temporary leave from the facility is ineffective. The manager was unsure if all persons in care leaving the facility has identification on them.
      • RB1.18A - Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system for ensuring secure storage of hazardous materials is ineffective. There are door securing devices on the dishwashers in the communities. The securing devices were not being used while the dishwashers were on. The Licensing Officer had opened two of the dishwashers during the inspection and hot steam emitted from them.
      • 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)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The system for ensuring compliance with medications is ineffective. Several over the counter medications were found in a persons in care bathroom. This item has been noted on previous inspections. The medications were removed during the inspection. The Care and Service Manager made aware that this is an ongoing issue and will be following up on the process as well as the care plan.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system for ensuring persons in care are in possession of identification on them when on temporary leave from the facility is ineffective. The manager was unsure if all persons in care leaving the facility has identification on them.
      • 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 )
  12. Monitoring

    4 infractions

    • RB1.22 - Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): As previously noted in the inspection: One of the cupboards containing person in care records was found to be unlocked during the inspection. The cupboard was locked during the inspection. (CDI = corrected during inspection)
      • RB1.22A - Respect personal privacy and keep records and personal information confidential.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system for ensuring compliance with regular performance evaluations is ineffective. Several staff evaluations are over due.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): One of the cupboards containing person in care records was found to be unlocked during the inspection. The cupboard was locked during the inspection. (CDI = corrected during inspection)
      • R4.1S - 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
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The system for ensuring compliance with medications is ineffective. Several over the counter medications were found on the counter in a persons in care bathroom. This remains outstanding from the previous inspection.
      • 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)
  13. Monitoring

    4 infractions

    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): A sampling of person in in care records were reviewed. A professional assessment was completed and it was noted that a person in care was assessed at a high risk for falls with the recommendation of hip protectors. There was no mention of the use of hip protectors in the persons in care my day or falls prevention care plan. This was corrected during the inspection.
      • Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (Show More)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Nail polish remover was found in a persons in care unlocked bathroom cupboard. This was corrected during the inspection. Prescription treatment creams were found on a person in cares bathroom counter. This was corrected during the inspection.
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
      • Ensure all medications are safely and securely stored; 69( 3 )(a)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): Over the counter analgesic cream was found in a persons in are unlocked bathroom cupboard.
      • Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
    • 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): A sampling of person in care records were reviewed and a significant weight change was noted in two persons in care records. There was no notification or follow up from a health care provider noted with these weight changes.
      • Seek immediate advice from a health care provider if a person in care has experienced unintentional and significant change in weight; 83( 4 )(b)
  14. Monitoring

    6 infractions

    • 25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): As noted in the inspection report; care plan had not been developed on a person in care residing in the facility for greater than 30 days.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Although the facility completes several audits and surveys, it does not have a plan in place to regularly monitor the environment or the care services to ensure that the requirements of the Act and the Regulation are being met.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): The Licensing Officer was unable to locate information by which a person may be described on a persons in care record. A care plan had not been developed on a person in care who had been admitted for over 30 days. Monthly weight was missed being recorded in the records of a person in care. It was noted on the weight sheet posted in the bathing rooms that several weights were missed being recorded in the month of February. The Director of Care explained that weights are recorded in the bath binder and my not be recorded on the sheet posted in the bathing room. There was a shift routine posted on the fridge in one of the communities containing personal information on persons in care. This was removed and corrected during the inspection.
      • 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)
      • Ensure a care plan is developed within 30 days for persons in care admitted for more than 30 days; 81.1; Director of Licensing Standards of Practice: Advance Directives and Care Plans
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83(4)(a)(c)
      • 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): A toilet paper roll noted to be contaminated with what looked like to be fecal matter in a persons in care bathroom posing the risk of cross contamination by the person in care to other areas of the facility. The toilet roll was replaced during the inspection. Further preventative measures will need to be established by the facility in regards to monitoring and preventing reoccurrence.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 (1)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Damage to walls noted in several areas as well as a damaged cupboard noted in one of the communities. Several ceiling tiles throughout the facility noted to have water staining on them. The maintenance man stated that this staining is from condensation of the air conditioning equipment. Dust noted in vents in community kitchen and debris noted in light fixtures through out the facility. The dishwashers in the communities are accessible to persons in care. There was no shelter or seating provided in several of the outside areas accessible to persons in care.
      • 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)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35(1)(c)
      • Provide outside activity areas that have comfortable seating including a reasonable amount of shelter from sun and inclement weather; 36 (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): Care plan had not been developed on a person in care who has resided at the facility for over 30 days. Oral care plan was incomplete, nutritional care plan had not been developed by the dietician and there was no recreation plan noted in the record of the person in care.
      • Care plans must includes an oral health care plan; 81(3)(b)
      • 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)
      • Care plans must include a recreation and leisure plan; 81(3)(d)
      • 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)

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