Pioneer Lodge
133 11 Ave S Cranbrook BC V1C 2P4 · Residential Care - Licensing
9 inspections
- Routine Inspection
2 infractions
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): R7.1I - Multiple electrical outlets accessible to persons in care were observed without protective covers. This presents a potential risk of electrical shock or injury to individuals in care. Submit by December 31, 2025, a written plan outlining how the contravention related to ensuring that all rooms and common areas are maintained in a good state of repair, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 22(1)(b) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward. R7.1AK- During the inspection of the physical facility, the key for the medication cabinet was accessible to persons in care in an unlocked drawer attached to the medication cabinet. The key was removed and locked in the staff area at the time of the inspection. Access to prescription medications poses several risks to persons in care, especially those who may have cognitive impairments or other vulnerabilities. Submit by December 31, 2025, a written plan outlining how the contravention related to ensuring that access to hazardous materials, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 35(1)(c) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- 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): R10.3A - A review of care plans identified that one care plan lacked specific guidance for staff regarding a person in care’s unique abilities related to their diagnosis. While this information had previously been communicated through a separate communication tool, the care plan does not currently provide clear direction to staff to ensure care requirements are met and proper implementation is maintained. Without clear guidance in care plans, there is a risk that staff may not provide care in alignment with the person in care's preferences, which may impact their health, safety and dignity. Submit by December 31, 2025, a written plan outlining how the contravention related to ensuring care plans take into account the unique preferences of persons in care has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 81(4)(a) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Routine Inspection
2 infractions
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): It was identified during the inspection that the system to ensure there is a fall prevention plan for those identified as prone to falling is ineffective. During a chart review it was noted that a recent falls risk assessment was completed indicating a person in care to be a high falls risk. There was no corresponding fall prevention plan in place for preventing the person in care from falling, or a plan for following up on any falls suffered by the person in care. This is a re-occurring contravention from the November 2023 inspection report.
- 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)
- 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): It was identified during the inspection that the system to ensure a care plan included a plan to address as needed medications (PRN) was ineffective. It was identified during the inspection that the system to ensure care plans include a plan to address behavioral intervention is ineffective. During a chart review, and discussions with employees, it was identified that a person in care with varying behaviors did not have a care plan to address behavioral interventions. This is a re-occurring contravention from the November 2023 inspection.
- R10.3B - Care plans must include a plan to address medication, including self-medication; 81( 3 )(a)(i)
- R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Routine Inspection
4 infractions
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): It was identified during the inspection that the system to ensure there is a fall prevention plan for those prone to falling is ineffective. During a chart review it was noted that a recent falls assessment was completed indicating a person in care to be a high falls risk. There was no fall prevention plan in place for preventing the person in care from falling, or a plan for following up on any falls suffered by the person in care.
- 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): The system to ensure policies are implemented by employees is ineffective. It was identified during the inspection that the policy and procedure pertaining to Residential Care was not implemented by employees.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): The system to ensure each person in care is weighed and the weight is recorded 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): During a random chart review it was identified that the system to ensure care plans include a plan to address behavioral intervention is ineffective.
- R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Routine Inspection
2 infractions
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): During the inspection it was noted that the common rooms, and bathrooms were not maintained in a good state of repair. This was evidenced by missing, and possibly moldy grout in the bathroom, scratched and chipped paint on baseboards, walls and railing, and damaged walls.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(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 to ensure each person in care has a care plan to address medication was ineffective. During an audit of the medication administration records it was noted that persons in care were missing a plan to address medication.
- R10.3B - Care plans must include a plan to address medication, including self-medication; 81( 3 )(a)(i)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Routine Inspection
2 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): It was noted during the inspection that a door leading to the basement was unlocked, therefore, accessible to persons in care. This contravention was corrected during inspection.
- 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): It was noted during the inspection that monthly weights of persons in care were not being completed consistently. It was also noted that the system for ensuring monthly weights of persons in care that do not self ambulate was 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)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection
0 infractions
- Monitoring
8 infractions
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): The system for monitoring the environment in regards to preventing falls for person in care is ineffective: -Mats in shower and bathtub do not provide adequate slip resistance for persons in care. -Floor transition strips throughout facility are raised and present tripping hazard to persons in care.
- R7.2P - Ensure bathrooms have slip resistant material on the bottom of each bathtub and shower; 30(b)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): The system to assess, prevent and follow up on those persons in care prone to falling is ineffective. The care plan provided to Licensing does not contain: -An assessment of the person in care. -A plan for preventing the person in care from falling. -A follow up plan on any falls suffered by the person in care.
- 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)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Inform Licensing of the system and/or audit you will put in place to ensure that the physical environment & the care and services provided to persons in care meet the requirements of the Community Care and Assisted Living Act and the Residential Care Regulation (RCR).
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- RB1.18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
- RB1.18A - Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
- 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): Emergency plans do not indicate plans or procedures for how persons in care will continue to be cared for in the event of any emergency.
- R2.1G - Have a plan that sets out how persons in care will continue to be cared for in the event of an emergency; 51( 1 )(b)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Manager advised that annual staff performance evaluations have not been completed. Inform Licensing on the system you will implement to ensure regular monitoring of employees. Discussion about acting manager in the absence of the facility's manager. Manager was able to advise LO's about an on call phone list that employees could use in the event of an emergency. The process did not designate one employee qualified to supervise employees, coordinate/monitor persons in care. Inform Licensing on the system your facility will put in place to ensure the manager is replaced by a qualified employee during a temporary absence.
- 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The system for ensuring that all rooms are in a good state of repair is ineffective: - One bedroom has several small holes and chipped drywall on the walls in need of repair/paint. - Other main floor bathroom appeared to have walls in need of repair/paint. Main floor bathroom: -Grout/caulking around bathroom tile and toilets (appeared black) and in need of replacement. - Transfer pole beside toilet has duct tape around the base of it and is in need of repair/replacement. Second level/and outdoors: -The railing on the fire escape exit stairs is unstable and in need of repair/paint (wood sliver hazard for persons in care). -Black mould was present on the wood framing of windows in common area and 2 bedrooms. -Picnic table in backyard in need of repair/paint. The system for ensuring that the safety and cleanliness of all rooms and common areas are maintained is ineffective: Main Bathroom: -Pink mould identified on mat on bottom of shower. -Bathtub had visible debris (dust, dead bugs on bottom). The system for ensuring that all hazardous materials & cleaning agents are safely and securely stored is ineffective: -Persons in care have access to the basement which stores maintenance tools and other miscellaneous household items. -Electrical extension and cable cords hanging in carport area and back fire escape staircase. -Windows of the facility open in a manner that does not prevent a person in care from falling from or exiting through. -Persons in care had access to Comet brand cleaner in unlocked janitorial closet. Corrected during Inspection (CDI). Emergency exit in common room was obstructed by air conditioner. Main bathroom door does not have a lock that can be opened from the outside in case of emergency.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
- R7.1AB - Bathrooms must have a door with a lock that can be opened from the outside in case of an emergency; 30(a)
- R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Main bathroom has open concept layout that does not ensure respect for privacy.
- R10.2F - Ensure respect for personal privacy of each person in care, including privacy of each person’s bedroom, belongings and storage area; 53
- R7.2 - Is the environment maintained to prevent falls?
- Monitoring
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Caulking and tile grout in places throughout the main floor bathroom is missing or in need of replacement. In addition, some of the caulking adjacent to the toilets is black in colour.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Monitoring
5 infractions
- 8.1 Is there an ongoing planned program of physical, social and recreational activities?
- Observation(s): Licensing observed that the facility is not monitoring and documenting participation in recreational activities. There is an ineffective tracking process in place to record activities.
- Encourage persons in care to participate in the program of activities provided (Does not apply to Hospice); 55( 1 )(b)(i)
- Encourage persons in care to take advantage of physical, social and recreation opportunities available in the community (Does not apply to Hospice); 55( 1 )(b)(ii)
- 13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
- Observation(s): Licensing observed that the facility is not monitoring and documenting participation in recreational activities. There is an ineffective tracking process in place to record activities.
- Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
- 25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
- Observation(s): Care plan review noted: Process in place is ineffective to identify and ensure the persons at risk of leaving the facility are identified and an elopement care plan is implemented.
- 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Licensing observed that there is an ineffective system in place to ensure PIC who leave the facility unannounced have written documentation or an ID bracelet to provide information about the PIC if they could not identify themselves.
- 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 )
- 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)
- 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 review noted: Process in place is ineffective to identify and ensure the persons at risk of leaving the facility are identified and an elopement care plan is implemented.
- Care plans must include a recreation and leisure plan; 81( 3 )(d)
- Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
- 8.1 Is there an ongoing planned program of physical, social and recreational activities?