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Piccadilly Care Center

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

13 inspections

  1. 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
  2. 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)
  3. 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)
  4. Routine Inspection

    0 infractions

  5. 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)
  6. 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)
  7. 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)
  8. Substantiated complaint

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The complainant expressed a concern that the licensee did not report an incident to licensing. Licensing reviewed the facility records and noted an incident report had not been submitted to Licensing. The licensee had determined the incident was not reportable, however, it does meet the criteria as defined in Residential Care Regulation Schedule D. Licensing finds this complaint substantiated. The complainant expressed a concern that the licensee did not notify the person in care's medical practitioner or contact person/representative when involved in a reportable incident. Licensing reviewed the facilities internal incident report and notifications were documented. Licensing finds this complaint unsubstantiated.
      • R4.5B - Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77( 2 )(a)
      • R4.5C - Immediately notify the medical or nurse practitioner responsible for the person in care involved in a reportable incident; 77( 2 )(b)
      • 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): The complainant expressed a concern that record keeping is not maintained nor regularly monitored by the licensee. The licensee was unable to provide some of the documentation requested by Licensing as it had not been completed. The licensee acknowledged monitoring has been challenging due to staff shortages. The system in place for monitoring the care and services provided is ineffective. Licensing finds this complaint substantiated.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The complainant expressed concerns mail was held by the licensee without documentation to explain the reasoning, duration to be held or plan for follow up which led to a person in care becoming behind in bill payments. The licensee informed licensing that records pertaining to the person in care's mail being held by the licensee were not kept. Licensing finds this complaint substantiated.
      • R4.1K - Keep a record of all money, valuables and other things held by the licensee in trust or safekeeping for persons in care; 79( 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 expressed a concern that a person in care's behavioural care plan did not address interventions. Licensing reviewed the behavioural care plan and interventions to guide staff were documented. Licensing finds this complaint unsubstantiated. The complainant expressed a concern that care conferences are not completed when there is a substantial change in the circumstances of the person in care. Licensing reviewed the facility care conference and care plan policies as well as progress notes and care plans. Licensing was unable to find evidence of completion. The licensee acknowledged some care conferences have not been scheduled as per policy to review and modify care plans. Licensing finds this complaint substantiated.
      • 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)
  9. 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)
  10. 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 )
  11. 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)
  12. 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)
  13. 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)