Pine Grove Care Centre Partnership
313 McGowan Ave Kamloops BC V2B 2N8 · Residential Care - Licensing
21 inspections
- Routine Inspection
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): One bedroom of a person in care has a heater with several bent and broken radiator grate sections. One bedroom of a person in care has an exposed screw where a handle of a drawer was half pulled off. When sharp edges and sharp screws are exposed and accessible to persons in care, risk of physical injury is greatly increased. Submit an action plan outlining how the Licensee will ensure that physical facility maintenance is completed regularly, no later than April 13, 2026.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Routine Inspection
2 infractions
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): In one dining room freezer, one bowl with a food item was found, uncovered. Staff immediately removed the food item and disposed of it as there was no indication how long the item had been present. *Staff removed the food item immediately and fixed the issue. When food is not stored in a safe manner, risk of food borne illness affecting persons in care is increased. Submit a detailed action plan stating how the Licensee will ensure food is stored in a safe manner no later than December 22, 2025.
- R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): A review of person in care’s monthly weights showed two persons had no weights taken in September 2025, and no reason for weights not being obtained was found. When monthly weights are not taken for all persons in care, this increases risk of health issues occurring as data is not collected and assessed. Submit a detailed plan stating how the Licensee will ensure staff are documenting the reason why person in care monthly weights were not able to be obtained no later than December 22, 2025.
- R10.3S - Record in the nutrition plan the reason why a person in care has refused or is unable to be weighed and that immediate advice is sought of a health care provider when it appears that a person in care may have experienced a significant change in weight; 83( 5 )(a) (b)
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Routine Inspection Follow-up
4 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): RCR section 74(1) Substantiated Finding: The incident report, the person in care’s progress notes and the interview notes of all staff interviewed were reviewed. There was no written agreement, and no assessment had been completed for use of an emergency restraint. When assessments to apply restraints are not completed for appropriateness and necessity, or there is not a written agreement in place, the risk of injury or death of the person in care is increased. Submit a detailed correction plan of how the Licensee will ensure staff will follow all policies and legislative requirements for restraints, no later than November 14, 2025.
- R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): RCR 74(2)(b) Substantiated Finding: On review of the interview notes of the alleged staff, they stated in their interview they had applied the straps to the person in care's legs because they were "busy" during their shift. When restraints are applied for the convenience of staff, this increases risk of injury or death to persons in care. Submit a detailed corrective action plan that details how the Licensee will ensure that staff will not apply restraints for the convenience of employees, no later than November 14, 2025.
- R10.4L - Ensure a person in care is not restrained for the purpose of punishment or discipline, or for the convenience of employees; 74( 2 )(a)(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): RCR section 85(1)(d) Substantiated Finding: The Licensee’s policies were reviewed and found that the staff involved did not follow the “Least Restraint” and the “Prevention of Abuse” policies. During the investigation it was determined that the staff wrapped the lower straps of the person in care’s transfer sling around their upper legs. This finding was also supported by the internal review completed which found that the staff had “applied inappropriate restraints”. When staff are not following legislative requirements and the Licensee's policies, this increases risk of injury and/or death, and affects health, safety and dignity of persons in care. Submit a detailed correction plan of how you will ensure staff are following the Licensee’s policies, no later than November 14, 2025.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- 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): RCR 82 Substantiated Finding: The person in care’s restraint care plan was reviewed and the use of leg straps of a transfer sling as a restraint was not included. Therefore, staff did not follow the care plan. The Licensee's review supported this finding. When care and supervision are not consistent with the care plan, risk of injury or death is increased and care provided is not appropriate to meet the needs of persons in care. Submit a detailed correction plan for how you will ensure staff are understanding and following care plans as they are written, no later than November 14, 2025.
- 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
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Routine Inspection Follow-up
1 infraction
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Two reportable incidents were submitted to Licensing Direct on August 8, 2025. One of the reportable incident occurrence dates was August 2 and the other reportable incident occurrence was dated as August 3. There were no concerns with the details of the incident reports, only that they were not submitted as per legislative timelines. *This is a repeated contravention, and the Licensee is under progressive compliance for reportable incidents being sent in late. When reportable incidents are not reported immediately, as per legislation, this increases the risk that the approach of the Licensee may not be as fulsome as is required to ensure safety of all persons. Submit a detailed corrective action plan no later than August 25, 2025, for how gaps in the reporting system will be repaired and how all reportable incidents will be reported immediately to Licensing. Previous written action plans are no longer valid.
- 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
3 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): A scheduled Service Delivery Problem occurred the day before the inspection for which a Health and Safety Plan was presented during the inspection which had not been submitted to Licensing for approval. An Incident Report was received on the day of the inspection. *This is a repeated contravention. When a Health and Safety Plan is not sent and approved by Licensing, this increases the risk that the approach of the Licensee may not be as fulsome as is required to ensure safety of all persons. Submit a detailed corrective action plan for how incidents and all other communication measures required by Licensing are completed in a timely manner, no later than June 23, 2025.
- 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)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Performance reviews were not completed for approximately 3/4 of the staff at the time of this inspection. *This is a repeated contravention. When performance reviews are not completed for all staff, the risk of staff not having the required competencies is increased, thereby increasing risk to persons in care. Submit a detailed corrective action plan for how all performance reviews will be completed in a timely manner, no later than June 23, 2025.
- R3.1N - 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): RCR 22(c) – The cleaning and sanitizing process of nail clippers was reviewed and found that the product being used was not indicated for this type of tool cleaning, per manufacturers instructions. Using a product that is not indicated for specific personal hygiene tools increases risk of those tools not being properly cleaned and sanitized, thereby increasing risk to persons in care and their health. Submit a detailed corrective action plan for how personal hygiene tools will be cleaned and sanitized per the manufacturer’s instructions no later than June 23, 2025. RCR 35(1)(c) - A storage shed in the outdoor area was unlocked and gardening tools were found inside, including gardening shears and accessible to persons in care. Leaving gardening tools accessible to persons in care increases the risk of harm to themselves or others. Submit a detailed corrective action plan for how all areas of the facility will be monitored for items which may cause harm to persons in care when left accessible no later than June 23, 2025.
- 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Substantiated complaint
5 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): RCR 74 – Contravention arising from investigation: As the person in care was reported by the complainant to have been sitting in a “Broda” chair at the time of the fall being investigated, the person in care’s current restraint written agreement was reviewed. The agreement showed that there was no signature included of a medical practitioner or nurse practitioner, as is required by legislation.
- R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): RCR 81(3)(a)(iii) – Allegation: The Licensee did not include appropriate care planning for falls prevention to prevent the fall from occurring. A review of a person in care’s care plan, and progress notes, in comparison to the facility's "Falls Policy" indicated the need for falls interventions which were not in place when the fall was sustained. During the investigation, this lack of intervention was confirmed by the Manager to not be in place on the day the person in care sustained a fall. FINDING: The allegation is SUBSTANTIATED.
- 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)
- 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): RCR 85(1)(d) – Contravention arising from investigation: During the investigation, a review of the related fall incident report, the facility’s hospital transfer memo to nurses, and the facility's post falls policy, it was determined that an employee did not follow facility's policy related to hospital transfers, as the nurse was under the understanding the doctor was calling 911 for hospital transfer, when facility process dictates it is the nurse who calls 911.
- 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): RCR 40(1)(a)(b) – Contravention arising from investigation: As part of the investigation, employee files were reviewed and the orientation documentation for one employee in their file was found to be blank. The manager confirmed that the employee had not returned their orientation form at the end of their scheduled orientation, and they had no way to verify orientation had been completed. RCR 43(1)(a)(b)(c) – Contravention arising from investigation: As part of the investigation, first aid certificates were reviewed for the employees involved, and who are required by the facility to have obtained the credentials in order to be in compliance with this piece of legislation. The first aid certificate of one employee was reviewed and it was determined the certification did not meet legislative requirements. Confirmation with the Manager determined the provided first aid certification was the only first aid certificate available in the employee file.
- R3.1N - 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)
- R3.1R - 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)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): RCR 50(1) – Allegation: The Licensee did not provide sufficient falls prevention measures to ensure the person in care did not fall. A review of the person in care’s care plan dated December 14, 2024 (the date of the fall sustained), and progress notes in the person in care’s chart were reviewed. The care plan was found to be inconsistent with documented behaviors in the progress notes dated before December 14, 2024, which increased the risk of falls for the person in care. FINDING: This is a SUBSTANTIATED finding. Harmful actions not permitted (Neglect) RCR 52(1)(a) – Allegation: The employees of the facility were neglectful to obtain emergency care in a timely manner which resulted in neglect. A review of the related fall reportable incident report, the progress notes of the person in care’s chart, and the written witness accounts showed that while the ambulance was not called for immediately by the attending nurse after the first conversation with the doctor, the employees did continue to monitor the health status of the person in care. FINDING: The allegation is UNABLE TO BE SUBSTANTIATED.
- R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Routine Inspection
5 infractions
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): The facility policy of restraints was reviewed as part of this inspection, and was not in alignment with the legislation regarding definitions of restraints, and therefore monitoring of PIC's who are in Broda chairs, tilt chairs, etc. (that were defined incorrectly as not being restraints) were not currently in place, as per legislative requirements.
- 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): During the inspection, the late reporting of incident reports was discussed. It was discovered that the facility does not have a sufficient process for immediate reporting when the manager is not onsite, and this is the reason the late reporting of incidents had been ongoing. (There is currently an ongoing Progressive Compliance Letter on File, due to this being REPEATED contravention).
- 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)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): A review of staff files showed staff who have been employed by the former contractor have not had updated Criminal Record Checks (CRC) completed by the current contractor, which makes the CRCs on file invalid as they are not addressed to the current employer. Performance reviews were not up to date for any of the staff at the time of this inspection. The new manager has been undergoing training and orientation, and training pertaining to performance reviews is not yet completed. (This is a REPEATED contravention)
- R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
- R3.1N - 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): Two razors were found in an unlocked bathroom cupboard in one person in care's private bathroom, leaving them 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)
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): The facility provided a medication storage inspection form, which was not completed by the designated pharmacist. It was then discussed that the facility has not had a designated pharmacist available to them for approximately 3 months. The previous medication storage area inspection had been completed by the former pharmacist on March 20, 2024. The manager reported they have had remote oversight from a "covering pharmacist" during those 3 months, but no onsite visits, and therefore did not have the required person to complete the medication storage inspection.
- R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(b)
- R4.3 - Is documentation concerning restraints adequate?
- Substantiated complaint
4 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): A review of the person in care's (PIC) chart did not show evidence of a written agreement for use of restraints that included the PIC's representative(s) and the medical practitioner, when restraints were included in the person's care plan and being applied on a regular basis.
- R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
- R10.1 - Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
- Observation(s): Licensing received a complaint that the PIC had been taken into the common area of the facility dressed in a shirt, incontinence brief, and covered in a blanket, which led to a loss of dignity for the PIC. This incident was confirmed by staff as having occurred.
- R10.1A - Promote the health, safety and dignity of persons in care; CCALA 7( 1 )(b)(i)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): On one occasion, a family member was asked to leave the facility during a meal time, and the family member was informed by a staff member that this was because "no family were allowed to be present during meals". This request was confirmed by the manager to not be in alignment with the facility policy.
- R10.2O - Ensure persons in care can receive visitors of their choice at any time and communicate with them in private, to the greatest extent possible, while maintaining the health, safety and dignity of all persons in care; 57( 2 )(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): A review of the PIC's chart showed documentation where a nurse did not follow the written and approved care plan for a wound that was being treated.
- 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
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Routine Inspection Follow-up
3 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): The facility submitted a reportable incident several days after the occurrence of the incident, rather than "immediately", and was reviewed and discussed during this inspection, along with requirement to report incidents immediately, per legislation
- 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): A compliance plan written by the facility as a response to the May 8, 2023 routine inspection, was reviewed during this follow up to routine inspection. The following was found to have not been in compliance with the accepted plan: -Spa Rooms audits were not available at this inspection for review. The facility had a separate follow up to routine on -Monthly Audits of RCA tasks were not available during inspection, and evidence of the audits not having been completed was identified during inspection (no charting of care having occurred in one person in care's record) -Fridge audits for food - no evidence of this having occurred since the last follow up to routine inspection
- 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): The following was noted during the inspection: -The policy of nurses resolving a care plan when no longer required was not followed in persons in care records (For example, a wound care plan was no longer required as wound had healed some time ago, but the care plan had not been resolved when the care plan was no longer required) -The policy of orientation of employees was not followed, as demonstrated by one staff on shift had not been orientated to a policy related to laundry practices and safety for sling safety
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection Follow-up
0 infractions
- Routine Inspection
6 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): During the inspection, it was noted there were three incidents which met the definitions of "reportable" as per RCR Schedule D that had not been reported by the facility to Licensing from February and March 2023. Therefore the facility did not report reportable incidents to Licensing in a timely manner. There were no available information logs of minor accidents, illnesses, etc. during the inspection.
- 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)
- R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(a)
- RB1.8 - Is there access to a fair, prompt and effective process to express concerns, make complaints or resolve disputes within the facility?
- Observation(s): As stated in R2.1V, the facility did not have the dispute resolutions process available.
- RB1.8C - Ensure access to a fair, prompt and effective process to express a concern, make a complaint or resolve a dispute.
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Evidence of effective monitoring and self auditing practices for ongoing physical environment safety, care and services were not demonstrated during this inspection. Examples include: -In all kitchenette areas, food items and juice thickeners were left open and accessible to persons in care -Audits of mobility slings condition as related to safety were not completed, per facility policy timelines
- 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): The dispute resolution process policy was not able to be located during the inspection and was not posted in the facility. In one person in care's room there was evidence of use of non-medical oral cannabis products, which contradicts the facility policy. The Licensee informed Licensing that the family wish to continue with this practice, even though the facility policy does not currently support it.
- R2.1V - Ensure there are written policies and procedures for how persons in care, their parents or representatives and contact persons may express concerns, make complaints and resolve disputes under section 60; 85( 2 )(d)
- R.2.1AF - Make a policy regarding the possession and disposal of tobacco, e-cigarettes and cannabis on the premises; 23(3)(b) Ensure the policy required under subsection 3 includes restrictions on those activities on the premises; 23(4)(a)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): A review of employee files showed one employee file had multiple complaints recorded, but had no information available to demonstrate the staff's performance had been reviewed. Licensee was unaware of performance management action plans/follow up for staff performance management as related to complaints and reportable incidents. Licensee and contracted staff manager communication processes and staff assessment processes were unclear at the inspection. At the time of the inspection, the facility had one staff designated in a supervisory role and "covering" four areas of supervision where there are usually four supervisors. One of the four areas requiring a supervisor has an ongoing plan of support, and the other areas did not have a support plan in place for the supervisor covering all areas. Medication Safety Advisory Committee "Medication error incident information/education and follow up provided" reviewed during the inspection was insufficient to demonstrate staff are following policies and procedures of the medication safety and advisory committee, or what actions had been taken post incident to mitigate reoccurrence by medication safety advisory committee.
- 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)
- R3.1N - Designate an employee qualified by training and experience to supervise employees who provide care to persons in care, coordinate and monitor the care of persons in care and manage unusual situations or emergencies; 41( 2 )(a)(b)( c)
- R3.1X - 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): In two wings, there were medicated creams and ointments left on the care carts, accessible to persons in care. In one of the tub rooms, there was a small bucket of approximately 30 nail clippers with no labels indicating who they belong to and it was reported all nail clippers are "cleaned" using tub cleaner.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Substantiated complaint
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The complaint received described that the outdoor area for persons in care was littered with garbage from new equipment that had arrived to the facility, making the area unsafe for persons in care to enjoy the outdoor space due to tripping hazards. The manager agreed this was accurate and had already executed a plan to have it cleaned out and made available to persons in care. Evidence of completion of the plan was provided on March 31, 2023. The complaint included that there was excess equipment in the same area, making the covered portions of the outdoor area unusable by persons in care and not able to be sheltered from sun and inclement weather as the equipment was present in the area. The manager again agreed this had been accurate and had already executed a plan to have it cleaned out and made available to persons in care. Evidence of completion of the plan was provided on March 31, 2023.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R7.1AN - Provide outside activity areas that have comfortable seating including a reasonable amount of shelter from sun and inclement weather; 36 ( 1 ) (c)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Routine Inspection
6 infractions
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Restraint check charting at times is completed at the end of the shift and not closer to the time the check was completed. This contravention was noted during the last routine inspection and found unresolved during this inspection.
- R10.4F - Employees administering a restraint must follow any instructions in the care plan of the person in care respecting the use of restraints; 73( 2 )(b)(ii)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The most recent routine inspection was not posted at the time of this inspection.
- 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)
- RB1.17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
- Observation(s): The most recent routine inspection was not posted at the time of this inspection.
- RB1.17A - Post the most recent routine inspection in a prominent place.
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): This site does not currently have a Food Service manager with CSNM qualifications, this contravention was noted as out of compliance during the last routine inspection. Licensing is requesting a detailed plan indicating the steps the licensee is taking to support this site with a CSNM qualified Food Service Manager.
- R3.1S - The food services manager must be either a nutrition manager with membership in the Canadian Society of Nutrition Management (CSNM), a person eligible for membership with the CSNM, or a dietician (Applies to 50 or more persons in care); 44( 2 )(a)(b)(c)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): In several areas of the outdoor courtyard, it was observed that old facility furniture (bed side tables, beds, freezer etc..) were stored, please ensure the courtyard area that is accessible to persons in care is not used for facility storage. A pull cart was also observed in the courtyard, this item could potential cause a tripping/falling concern, ensure this item is removed from the courtyard area.
- 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): Some persons in care had care plans in place due to potential identified wandering risk, which required monitoring that was to be charted. During this inspection the charting of the identified persons was noted to be sporadically charted.
- 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
- R10.4 - Are restraint and fall prevention plans appropriate?
- Routine Inspection
6 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): Ensure all restraints include a written agreement detailing the use of the restraint signed by the medical practitioner and representative.
- R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Reportable incidents received by licensing since November 2020 were reviewed in preparation for this inspection, incident reports should be reported immediately to licensing, some reports were received 2-3 days after the incident occurred. Inform licensing on what systems will be put in place to ensure incident reports are received immediately. This contravention was also noted during the last licensing routine inspection at Pine Grove.
- R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Restraint check charting observed during this inspection at times showed charting was completed for 6 hours of checks at the same time, the restraint plans observed indicated 2 hour checks of restraints. One care plan reviewed today in the Point Click Care system did not include a fall prevention plan.
- R10.4F - Employees administering a restraint must follow any instructions in the care plan of the person in care respecting the use of restraints; 73( 2 )(b)(ii)
- R10.4P - Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (Show More)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): Facility policy indicates any persons in care with a restraint in place are to be included on Sunflower Program form, at the time of this inspection one PIC with a current restraint had not been included on the form.
- 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): Facility currently has an exemption in place for RCR 44(2)(a)(b)(c) from October 26, 2021 until April 30, 2022, one of the timelines identified in the exemption request was to be completed by November 30, 2021, during this inspection it was reported to licensing that the timeline had not been met. Please inform licensing of the altered timeline that will be put in place to meet the intent of the approved exemption.
- R3.1S - The food services manager must be either a nutrition manager with membership in the Canadian Society of Nutrition Management (CSNM), a person eligible for membership with the CSNM, or a dietician (Applies to 50 or more persons in care); 44( 2 )(a)(b)(c)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Snacks are provided at the home, but information on the available snacks is not included in the posted weekly menu.
- R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Substantiated complaint
3 infractions
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): A medicine device which was required by a person in care was not reordered, until the issue was brought forward by the complainant.
- R7.2L - Ensure all furniture and equipment used by persons in care meet their needs; 21(a)
- 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 medication care plan was changed for the person in care identified in the complaint received by licensing, the representative for the person in care was not notified of the change per facility medication policy.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- 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 needs of the person in care changed, facility staff did make the change, however the care plan was not updated to reflect the new needs.
- 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)
- R7.2 - Is the environment maintained to prevent falls?
- Routine Inspection
4 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Reportable incidents submitted to Licensing since the beginning of 2020 were reviewed in preparation for this inspection, reports should be received immediately, some of the reports received 2-3 days after the incident. Inform Licensing on what systems will be put in place to ensure reportable incidents will be submitted immediately to licensing.
- R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Restraint checks are documented in PCC, but some of the checks are documented hours after they were completed. Inform licensing on what system will be put in place to ensure restraint checks are charted in a timely manner.
- R10.4F - Employees administering a restraint must follow any instructions in the care plan of the person in care respecting the use of restraints; 73( 2 )(b)(ii)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Performance review procedures for new staff are up to date, but regular performance reviews for long term staff are currently behind schedule. Facility currently does not have a Food Service Manager with CSNM qualification, an exemption request was received on September 28, 2020 in response to this contravention.
- 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)
- R3.1S - The food services manager must be either a nutrition manager with membership in the Canadian Society of Nutrition Management (CSNM), a person eligible for membership with the CSNM, or a dietician (Applies to 50 or more persons in care); 44( 2 )(a)(b)(c)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): ID for PIC's who have been assessed as an elopement risk was discussed during this inspection, the current procedures for ID have not always been successful, inform licensing on what changes will be put in place to ensure PIC's who have been assessed as a wandering risk have ID in place.
- R10.2M - Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56( 3 )(a)(b) (Show More)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
5 infractions
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): It was noted that Park Place Seniors Living has a policy and procedure to document Restraints every 2 hours, which was reflected on the new Point of Care electronic monitoring system; however, the paper document used at Pine Grove Lodge for restraint monitoring directed staff to document every 30 minutes. The Leadership team has indicated that the paper form will be updated to reflect Park Place Seniors Living policy and reflect practices of the new Point of Care electronic monitoring system.
- 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): The facility does not have a system in place to ensure that all new managers and employees are oriented to the Residential Care Regulations and the Community Care and Assisted Living Act.
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): It was determined that a Recreation Therapist/Aid who conducts outings with persons in care does not hold a valid first aid and CPR certificate.
- R4.4 - Are records kept on each employee with the necessary requirements?
- Observation(s): In review of staff files, 2 (out of 4) of the staff files did not contain TB records.
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): The facility has a system in place to monitor the fridge temperatures daily. A few dates were noted to not have fridge temperatures documented on the fridge temperature log. The new Food Services Manager was made aware of the issue.
- R4.3 - Is documentation concerning restraints adequate?
- Monitoring
4 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): Please update the facility admission package to include information on how a PIC representative can make a complaint to licensing. Pine Grove has recently instituted a policy that requires staff to chart daily in "Resident Care Logs", the charting was observed as inconsistently completed during this inspection. inform Licensing on how "Resident Care Logs" will be audited to ensure they are completed.
- 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)
- 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): Support staff performance evaluations are currently behind facility target dates for completion, inform Licensing on when they will be completed. Also include in your response what systems/audits will be put in place to ensure performance evaluations are completed by the facility established target dates.
- 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): Ice build-up/hanging icicles noted at the main entrance to the facility and at the main exit to the outdoor courtyard, ensure there is a system in place for all exit/entrance doors to ensure they are cleared of ice for the duration of the winter. Ice build-up has been noted in previous years at this facility, inform Licensing on what steps will be taken after the winter season to prevent similar issues in the future.
- 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): Some oral care plans reviewed during this inspection did not include specific details regarding day to day PIC oral care needs. Please review all oral care plans to ensure they are complete. Also include in your response how oral care plans will be developed and audited to ensure they are complete moving forward.
- R10.3D - Care plans must includes an oral health care plan; 81( 3 )(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?
- Monitoring
4 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Outdoor gardening equipment was found accessible to PIC's in the facility courtyard, a bench, a trellis and some fencing were observed in poor condition (paint chipping, wood deteriorating). Inform licensing how the facility self monitoring procedures include monitoring of the outdoor courtyard.
- 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): An exemption was in place for the facility to meet the intent of this regulation, circumstances specific to the exemption have recently changed, facility will submit a plan to Licensing on how they will meet the requirement of a Food Service Manager.
- R3.1S - The food services manager must be either a nutrition manager with membership in the Canadian Society of Nutrition Management (CSNM), a person eligible for membership with the CSNM, or a dietician (Applies to 50 or more persons in care); 44( 2 )(a)(b)(c)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Paint chipping and wood deteriorating observed in the outdoor courtyard on a bench, a trellis and fencing around the cement sitting area. Inform Licensing on how these items will be addressed. Gardening tools (shovels, rakes ) observed in an area accessible to PIC's in the courtyard, the items were removed during the inspection, inform licensing on what self monitoring procedures are in place to ensure potentially hazardous materials are not accessible to PIC's.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): The nutritional care plan for on PIC did not include specific supervision requirements for staff when the PIC involved chooses to eat in their bedroom. Inform Licensing regarding the update to the nutritional care plan for that PIC as well as how all nutritional care plans are audited on a regular basis to ensure the information correct and up to date. Recreation plans not in place for several PIC's who have been in care over 30 days. Inform Licensing that the plans for these PIC's have been completed and include what systems are in place to ensure all PIC care plans are completed before they have been in care for 30 days. Also include in your response how the care plan implementation system is audited by the facility.
- R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
- R10.3N - Develop a nutrition plan for each person in care and review the plan on a regular basis (Applies to a facility with 24 or fewer persons in care); 83( 1 )(a)( 3 )(a)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Monitoring
2 infractions
- 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Ensure the self monitoring procedure is updated to include on-going monitoring of the outdoor courtyard. Self monitoring documentation should include deficiencies discovered during checks as well as information on how the deficiencies have been addressed. Please keep copies of past self monitoring checks for review by Licensing when requested.
- Regularly monitor the physical environment and the care and services provided; 61
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Ceiling tile in one hallway shows staining marks from water damage, please fix or replace the tile. Window blind in one residents room is in poor repair, please fix or replace. Some benches in the outdoor courtyard require clean-up or repair prior to use by residents. Several of the benches have plastic covers which are covered in dust or in some cases water. One bench made of wood which is not covered has rough edges and missing paint and is in need of repairs. Weekly menu not posted in one dining area, the wrong weekly menu posted in the second dining area. Ensure weekly menu's are always posted in dining areas. Medicated creams observed stored in several resident rooms, ensure all medications are stored in designated medication storage areas.
- 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)
- Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
- Ensure all medications are safely and securely stored; 69( 3 )(a)
- 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Monitoring
5 infractions
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Current process for tracking which staff have valid first aid is not adequate. Current food service manager does not meet requirements specified in residential Care Regulation 44(2)(a)(b)(c), iform Licensing in writing on how facility will come into compliance.
- 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)
- The food services manager must be either a nutrition manager with membership in the Canadian Society of Nutrition Management (CSNM), a person eligible for membership with the CSNM, or a dietician (Applies to 50 or more persons in care); 44(2)(a)(b)(c)
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): Height and weight of PIC's on admission not always noted on records reviewed during this inspection.
- Record the height and weight of each person in care on admission; 49 (2)
- 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): Several food items in smaller dining room area stored improperly: crackers in cutlery drawer out of package, soup powder mixed in cupboard with lid off, and several items in fridge without labels or expiry dates.
- Ensure that food is safely prepared, stored, served and handled; 63 (1)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Several items noted which need maintenance to ensure in good state of repair: wooden bench in outdoor area is rough and needs maintenance, corner of wall off of main dining area has chipped paint and needs repair, concrete bench in courtyard has a metal plaque which has raised edges which requires repair, and items stored near courtyard exit gate which are meant to be disposed of or donated need to be moved. Emergency exit door off one wing of building had a build up of leaves which made door more difficult to open, ensure all emergency exits are kept clear at all times. This item will be addressed today (April 9, 2015). Propane tank stored in courtyard area and garden tool shed without a lock, ensure these items are kept inaccessible to PIC's.
- Maintain all rooms and common areas in a good state of repair; 22(1)(b)
- Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 (2)
- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35(1)(c)
- 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Several PIC's who have been assessed as a risk for wandering did not have identification on their person at the time of this inspection.
- Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56(3)(a)(b)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?