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Ponderosa Lodge

425 Columbia St Kamloops BC V2C 2T4 · Residential Care - Licensing

18 inspections

  1. Routine Inspection

    3 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): A written restraint agreement between the person in care’s decision maker, and the medical practitioner was not present within the person in care’s chart for an environmental restraint. When a written agreement is not completed for use of a restraint for a person in care with all required persons, this increases risk of inappropriate restraints being implemented and risk of injury is also increased as inappropriate restraints have not been properly assessed for use. Submit a corrective action plan detailing how the Licensee will ensure all persons in care who have been assessed to require a restraint have an annual written agreement completed, no later than January 28, 2026.
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): There were several missing fridge temperatures for two of the fridges in serving areas in the month of January. If food is not kept at safe food temperatures and monitored to ensure, this increases risk of food borne illness for persons in care. Submit a corrective action plan to address how the Licensee will ensure food temperatures are being taken as per Licensee guidelines, no later than January 28, 2026.
      • 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 wound care plan for one person in care did not include the frequency of interventions in the plan of care. As there was no frequency included, it was not able to be determined if the care plan was being followed appropriately. When a care plan is not followed appropriately for wounds, this increases risk of infection to the wound of the person in care, ultimately affecting the person in care’s overall health. Submit a corrective action plan to address how and how often the care plans will be reviewed to ensure they are complete in their directions, no later than January 28, 2026.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  2. Routine Inspection

    2 infractions

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): A review of December medication administration records in three person in care's charts showed missing signatures on each.
      • 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): A cupboard in an alcove off the dining room which is usually locked was found with a broken lock and a handle missing which left a screw exposed to persons in care. Within this cupboard, a pair of scissors was present and accessible to persons in care as well. The scissors were removed during inspection (corrected during inspection).
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  3. Substantiated complaint

    3 infractions

    • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): A review of a person in care's care plan for recreation and participation tracking of recreational programs showed evidence the person in care does not regularly participate in planned recreation programs. Ex.) In one month, the person in care participated zero times during all recreational programs. The care plan for the person had no specific interventions included to meet their personal needs with recreation provided by the Licensee.
      • R8.1A - Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55( 1 )(a)(i)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): A person in care's care plan included using a tilt wheelchair as part of their care (without a seatbelt, but in recumbent position). A tilt wheelchair falls under the definition of a "restraint" within the legislated definition, and facility policy definition, when in recumbent position. There was no evidence of a restraint care plan, written agreement, nor a plan of reassessment included in their plan of care regarding the regular use of the reclined tilt wheelchair.
      • 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): A person in care regularly refuses to have a bath, and the facility policy states a refusal is to be documented, with planned follow up actions, including review of care plan. A review of documentation showed a period of two weeks where nothing is documented regarding the person in care having received a bath, refusing a bath or any planned follow up actions.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  4. Routine Inspection

    6 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): A review of eight person in care's charts showed no evidence in two of the charts that admission screening for tuberculosis had been completed.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): A review of monthly weight documentation within one unit showed there were three blank areas without any documentation of monthly weight or reason for not obtaining a monthly weight. The staff person explained and provided the information of monthly weights is also captured within another document (using "charting my exception"), but this document had no evidence to support the monthly weights either being taken or a reason the weight was not taken either.
      • 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)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): When reviewing the posted menus for the facility, it was noted the snack offerings were not consistently offering a minimum of two food groups for all textured diets, as required by legislation. For the pureed diets, only "pudding cups" were listed at several of the snack times.
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Two plates with food items were found in one fridge of a servery wrapped in cellophane (no longer in its original packaging), and it had no date/label to identify when the food was prepared.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): In one "pod area", there was visible dust and dirt noted around the door frame of a shower room door.
      • 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): A review of a document within one person in care's chart, for capturing the task of repositioning as per the care plan, showed no documentation over several hours multiple times over the course of several days. The document which had been used in that chart was not consistent with the repositioning document used on other units to capture the completion of this task, within the facility.
      • 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
  5. Substantiated complaint

    7 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): There was no evidence of written doctor's orders for use of restraint or a written restraint agreement in the person in care's chart, during the timeframe of July 2023 to October 2023.
      • 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)
    • 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): See R10.1 of report.
      • 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): A review of the facility policy, and other documentation relating to monthly fire drills, showed no evidence that four monthly fire drills had been completed within the last year.
      • 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): A review of person in care's chart showed no evidence of an active representative or contact person.
      • R4.1E - Keep for each person a record showing the name and telephone number of the persons parent or representative, contact person and primary health care provider; 78( 1 )(c)
    • 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): There was no evidence that the person in care had been provided with an explanation to why they were not permitted to leave the facility unaccompanied; thereby, not providing for the person in care's dignity.
      • 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): Licensing conducted a review of assessments that indicated the person in care was deemed financially incapable. The person in care's care plan did not include plans to support the person in care with their ongoing fiscal needs during the process of assessment for trustee involvement.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 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): The person in care was assessed by the Licensee to be at a high risk of elopement. Licensing reviewed the person in care's elopement care plan, which included an environmental restraint. Required items outlined in the facility policy, titled Wandering/Missing Resident, were not included in the person in care's care plan while the environmental restraint was implemented.
      • R10.3G - 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)
  6. Routine Inspection Follow-up

    8 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): One person in care's restraint was documented in the "My Day". Staff stated that person in care did not have a restraint any longer and restraint monitoring is no longer applicable. This shows inconsistencies in documentation of restraints for persons in care.
      • R4.3A - Record the type or nature of the restraint used in the person's care plan; 84(a)
    • RB1.25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): See contraventions R4.1Q.
      • RB1.25A - Ensure care plans are developed within 30 days.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensee reported that the "project nurse" had not yet started as per compliance plan but will be in July 2023. It was previously outlined in the compliance plan that this "project nurse" was to "get all clinical processes reviewed and the staff educated on them". No notice of change of compliance plan had been given to licensing prior to inspection day.
      • R1.1S - Provide a plan to ensure health and safety of persons in care during an investigation; 12 ( 2 )
    • 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): Four of five person in care's charts reviewed had physical indication of behavioural care plans present. Purple dot indicators were inconsistent between the chart, physical indicators on the "My Day" (in person in care's rooms) and on their doors, which did not follow facility policy. For example, physical indicator on chart was present and no behavioural care plan found. In another chart, the behavioural care plan was present but no physical indicators in room or chart were present as per facility policy. It was verbally reported to licensing that the person in care refused to allow the physical indicator, but no documentation was provided to support this. Manager was unable to provide an alternative means for communication, to staff, of behavioural issues.
      • 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 current compliance plan schedule has been adhered to and manager is trending to come into compliance, yet several staff performance reviews remained incomplete during this inspection.
      • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): In one person in care's files reviewed, there was no evidence of a long term care plan having been completed since their admission, which the admission date was more than 30 days prior to the inspection.
      • R4.1Q - 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
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Pungent urine smell present in three of five person in care's rooms within one "pod".
      • 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): A review of one wound care plan showed evidence of the wound care plan's frequency was not being followed. There was no evidence of wound care having been completed, on two separate days, when the frequency was every second day in the care plan. * This is a repeated contravention.
      • 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
  7. Routine Inspection

    9 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): In one person in care's care plan for restraint, the type of restraint was not identified, and within the falls care plan, there was no reference of a restraint being used. A review of one restraint monitoring form showed no evidence of monitoring having occurred from 0700-1000 on the date of the inspection when checks were to be completed every hour, per care plan of person in care.
      • R4.3A - Record the type or nature of the restraint used in the person's care plan; 84(a)
      • 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): No evidence was provided to show the facility and licensee have been regularly monitoring the care and services provided. Examples include: -non-compliance by staff with monitoring neuro vital signs post fall -restraint monitoring was not being followed per protocol -wound care plans were not being followed per the frequency of the plan -no evidence was provided to show there are monitoring practices of the care and services provided in place and whether these practices are being followed
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • RB1.25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): See contraventions R4.1A, R4.1F and R4.1Q
      • RB1.25A - Ensure care plans are developed within 30 days.
      • RB1.25B - Ensure care plans include all required elements.
    • 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): A review of person in care records showed evidence of staff completing documentation different from the attached instructions of a neuro vital sign form. The documented times were either hourly, every 15 min, or a one and a half hour check, which is inconsistent with the instructions. The total amount of time to be monitored was not following the directions either, per the 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): Staff performance evaluations are overdue, and none were available as evidence during this inspection. This contravention has been ongoing at this site, procedures have previously been put in place to try and get caught up, but have been unsuccessful.
      • 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): A review of seven person in care's files showed no evidence of height and weight having been documented at admission in three of the files. In one of the seven person in care's files reviewed, there was no evidence of an emergency description, or photograph since admission to present. In one of the seven person in care's files reviewed, there was no evidence of a long term care plan having been completed since their admission, which the admission date was more than 30 days prior to the inspection.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
      • R4.1Q - 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
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): There was no evidence of Temperature checks for servery fridges/freezers on one of the floors, and there was no evidence of checks having occurred for three days on another floor. The manager remarked this duty has been taken over by the food services department. When Licensing spoke with a food service worker, they were not aware this was their duty to complete.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Evidence was provided for one Medication Safety and Advisory Committee meeting having last occurred June 2022. No evidence of any further meetings/med room inspections having occurred was able to be produced to the regularity of the meetings.
      • R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 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 two wound care plans showed evidence of the wound care plan's frequency was not being followed. In one care plan, there was no evidence of wound care having been completed for two days in a row during the month of March 2023, when the frequency was every second day in the care plan. In another wound care plan the wound care was documented having been completed every three days when the frequency was to be done every two days, per care plan.
      • 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
  8. Routine Inspection

    7 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): In a review of reportable incidents over the last year, the facility has been under reporting reportable incidents, including - Unexpected Illness - to licensing, please review incident reporting procedures and RCR Schedule D with staff to ensure incident reports are submitted as required.
      • 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): Some fall risk care plans observed did not include an assessment of the nature of the risk of falling and a plan to prevent the person in care from falling.
      • 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Staff performance evaluations are overdue. This contravention has been ongoing at this site, procedures have been put in place to try and get caught up, but have been unsuccessful.
      • 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): The Resident Data Sheet was observed as incomplete in some charting reviewed during this inspection.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Temperature checks for servery fridges/freezers not located during this inspection.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Facility has not had a Medication Safety Advisory Committee meeting in some time, this contravention was noted during the last routine inspection of the site and was not resolved during this visit.
      • R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (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): Care plans for person in care (PIC) who leave the facility independently to smoke or for outings do not include specific instructions for staff to follow ( timeframes for PIC to return, steps to take if PIC does not return by specified time, smoking assessments/plans etc...). Progress notes reviewed for a person in care, identified a behaviour that was not identified or planned for in their behavioural care plan. The behaviours noted in the progress notes were also not reported to licensing in a incident report for - Aggressive/unusual behaviour which is required. Some restraint checks were observed as not charted in the restraint tracking tools observed during this inspection.
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  9. Routine Inspection

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Some medication administration records reviewed during this inspection had missed signatures. Ensure staff are following facility policy for medciation charting errors.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Some staff performance evaluations are overdue, this contravention has been noted over the last several inspections, some progress has been made since the last inspection. COVID 19 has made it difficult to complete. Facility will submit a plan to get reviews up to date.
      • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Facility will re-establish the Medication Safety and Advisory Committee.
      • R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Facility has identification bracelets in place, but bracelets do not include facility name. The process for adding the facility name was adjusted during this inspection.
      • 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)
  10. Routine Inspection

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): One reportable incident was discussed during this inspection that had not been reported to Licensing as required. The incident was reported to Licensing Direct later the same day.
      • 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 plans do not always include specific instructions on how often they are to be monitored while in use. This contravention was noted during the last routine inspection and is not resolved.
      • R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Staff performance evaluations are overdue, this contravention has been noted over the last several Licensing inspections, a plan was submitted after the last licensing visit, but due to COVID 19 no progress has been made. Tracking procedure for staff with first aid/CPR is not in place, this contravention was noted during the last licensing inspection
      • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
      • R3.1O - Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
  11. Routine Inspection

    6 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Some restraint plans observed did not include how often they needed to be monitored when in use. The charting of restraint monitoring was observed as incomplete in several areas. These two contraventions were noted on the last Licensing routine 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)
      • R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Performance evaluations for some staff are overdue. There is currently no process in place to monitor the expiry dates of staff first aid/CPR. to ensure there is a staff with valid first aid/CPR on shift at all times.
      • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
      • R3.1O - Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Monthly weights were not charted for every month in the records reviewed during this inspection.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Hot water measured at 53 degrees Celsius in a PIC washroom at the time of this inspection.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): A MAR observed during this inspection indicated self administration of medication by a PIC, there was no doctors order available and it was not noted in the care plan.
      • R9.1G - Permit self-administration of medication when a plan is approved by the medication safety and advisory committee and medical or nurse practitioner, and is included in the person's care plan; 70( 4 )(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): Some PIC's are able to leave the facility independently, ensure their care plans include specifics on this process (how long are they able to leave? what steps are staff to take if they do not return in the identified timeframe? etc...). One chart observed as a purple dot, for resident aggression did not include a behavioral care plan. A few other behavioral care plans had not been reviewed within the last three months, which was indicated during this inspection as the facilities goal for reviewing. Wound care charting observed in two separate cases did not reflect the wound care plan in place.
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  12. Monitoring

    3 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): One restraint care plan reviewed did not include monitoring information,, another restraint plan reviewed indicated a specific monitoring plan but the monitoring observed for the restraint differed from the the identified plan. Ensure every restraint care plan details monitoring frequency.
      • 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)
      • R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Facility currently has ID bracelets for known wanderers, but they do not have an auditing system to ensure the ID is still in place. Inform Licensing on what systems will be put in place to ensure PIC's who have been assessed as an elopement risk will have their ID.
      • 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)
    • 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): Ensure care plans for PIC's who are able to leave independently include details of the procedures for staff to follow for their outings (how long are they able to leave independently? what are staff to do if they don't return by the expected time? do they have their ID? etc). Include in your response how these plans will be developed and audited.
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
  13. Monitoring

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Treatment administration charting observed this inspection was not always completed by staff, this infraction was also noted during the last licensing inspection. Licensing received a response from the last inspection indicating TAR's would be audited regularly to ensure charting was completed. Inform Licensing on what changes will be made to the facilities TAR auditing procedures to ensure all treatments are charted.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Facility incident reporting procedures discussed during this inspection; some incident reports are being received by Licensing missing required information (notification times/dates, facility follow-up to incident etc...), a recent reportable incident which was not submitted to licensing was also reviewed. Please review your incident reporting procedures and inform Licensing on what systems/audits will be put in place to ensure Licensing receives completed incident reports in a timely manner (1 business day). Incident reporting was noted as an infraction on the last licensing monitoring 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Performance reviews for some employees which were due to be completed in 2017 will not be completed by the end of the year. Inform Licensing on what systems will be put in place to ensure 2017 reviews will be completed soon so that 2018 reviews can be started.
      • 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): Some care plans reviewed during this inspection had incomplete oral care plans. Inform Licensing on what systems/audits are in place to develop and review PIC oral care plans to ensure they meet the needs of each PIC.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  14. Monitoring

    10 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Licensing is receiving incident reports in different formats and not in the required timeframes, review incident reporting procedures and update to ensure staff are following facility reporting procedures. Include an auditing plan in your response.
      • R2.2F - Ensure there are written policies and procedures regarding responding to reportable incidents; 85( 2 ) (j)
    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Treatment administration procedures discussed and observed during this inspection were not always being documented by staff, please respond on how this will audited to ensure it is documented and completed per procedure. TAR records were noted as incomplete during the last licensing inspection.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Review current incident reporting procedures to ensure Licensing as well as PIC's representative, doctor/nurse practitioner and funding receive notification of a reportable incident immediately. Incident reporting procedures must also include an auditing component for the facility to be able to review if reports are completed. Facility will submit an IR to Licensing for an incident that was discussed during this inspection which has not been reported.
      • 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)
    • RB1.5 - Are persons in care informed on how to express concerns or make complaints to the medical health officer or to the Patient Care Quality Office prior to admission?
      • Observation(s): A complaint process is in place but it may not be discussed with all PIC's and their representatives prior to admission. Inform Licensing on how all PIC's and their representatives are informed of facility complaint procedures prior to admission/during the admission process.
    • RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
      • Observation(s): Ensure PIC's who are to leave the building independently have a care plan which indicates specific information for staff regarding (time frames PIC is able to be out, what to do if they do not return on time, does PIC have ID? etc...)this plan should be developed in conjunction with PIC representatives and reviewed when needed. Include in Licensing response how a care plan for PIC's who leave independently is developed and reviewed. This infraction was noted during the last inspection of the facility.
      • RB1.23A - Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Facility will develop a self monitoring plan to monitor the physical environment as well as the care and services provided.
      • 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): A complaint process is in place but it may not be discussed with all PIC's and their representatives prior to admission. Inform Licensing on how all PIC's and their representatives are informed of facility complaint procedures prior to admission/during the admission process.
      • R2.1B - Prior to admission, advise of policies respecting: expressing concerns, making complaints, and resolving disputes; 48( 1 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): A system is not in place to document which staff have current first aid/CPR and when the certificates expire, develop a system which documents staff first aid/CPR certification to ensure PIC's have access to staff with valid first aid/CPR at all times.
      • R3.1O - Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Ensure weekly menu's are posted in a manner which allows PIC's or their representatives to review easily. Facility has a procedure in place to post weekly menus as well as a posting a larger print daily menu, the daily menu posted during this inspection in one dining area was on the wrong day, the weekly menu in one dining are was stored in a manner which would make it difficult for some PIC's to access. Please review menu posting procedures and include how the posting procedure will be audited.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
    • 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): Ensure PIC's who are to leave the building independently have a care plan which indicates specific information for staff regarding (time frames PIC is able to be out, what to do if they do not return on time, does PIC have ID? etc...)this plan should be developed in conjunction with PIC representatives and reviewed when needed. Include in Licensing response how a care plan for PIC's who leave independently is developed and reviewed. This infraction was noted during the last inspection of the facility.
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
  15. Monitoring

    5 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Treatment administration records were reviewed during this inspection, treatment charting was observed to be charted sporadically. Ensure procedure is reviewed and all treatments are charted.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Facility policy indicates no smoking on site, the centre courtyard had two coffee cans with many cigarette butts in each can. Ensure facility policies regarding smoking are followed.
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Documentation of staff records not stored on site, a checklist of staff qualifications is not available. Please develop a system that documents staff qualifications for review by Licensing during inspections. Facility manager Joanna Harrison is currently working on staff performance evaluations, this infraction has been noted over the past few Licensing inspections, facility has made progress on each inspection working towards having performance evaluations up to date.
      • Obtain character references for all employed persons; 37( 1 )(b)
      • Obtain a record of work history for all employed persons; 37( 1 )(c)
      • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37( 1 )(d)
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Handrails in several areas have chipping paint and are in need of maintenance. Courtyard areas require clean-up after winter (wipe down tables and chairs to allow PIC's to utilize).
      • 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)
    • 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): Ensure PIC's who are able to leave the building independently have a care plan which indicates specifics of this plan for staff to follow (time frames PIC is able to leave, what to do if they do not return on time, etc...), this plan should be reviewed with PIC representatives. Monthly weight charting reviewed, for one PIC record reviewed there was a significant weight change charted, details in chart did not indicate any follow-up taken regarding the weight change (Is the weight correct?, referral?). Manager notified and will follow-up.
      • Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b)
      • Seek immediate advice from a health care provider if a person in care has experienced unintentional and significant change in weight; 83( 4 )(b)
  16. Monitoring

    4 infractions

    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Performance evaluations are in the process of being completed and the facility manager has a plan to have all overdue staff completed by the end of the calendar year. This infraction has been noted at facility for the past several inspections but further progress has been made during each visit, progressive compliance plans will not be initiated at this time.
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Ensure a weekly menu is on display in a prominent place in each dining room which includes at least two daily nutritious snacks.
      • Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Two call bells observed during this inspection not answered for up to a ten minute time frame. Please review call bell procedure to ensure all calls are responded to promptly. Some PIC's are able to leave the building independently, they do have wrist band ID's but the bands do not include all required information. Ensure ID includes PIC name, facility name and contact information.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • 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): Wound care documentation reviewed during this inspection, some charting reviewed indicates wounds not always treated/charted as per wound care plan. Ensure wound care plans are charted and treated as per individual PIC wound care management plans.
      • 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
  17. Monitoring

    2 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Licensing has not been receiving incident reports for some incidents. Other incident reports received by Licensing have not been received in an acceptable timeframe (1 business day). LO Bullock reviewed current facility incident report procedures with facility Manager and Director of Care. Facility will revise incident reporting procedures and submit for review by Licensing.
      • Ensure there are written policies and procedures regarding responding to reportable incidents; 85( 2 ) (j)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): Licensing has not been receiving incident reports for some incidents. Other incident reports received by Licensing and funding have not been received in an acceptable timeframe (1 business day). LO Bullock reviewed current facility incident report procedures with facility Manager and Director of Care. Facility will revise incident reporting procedures and submit for review by Licensing.
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
      • Immediately notify the funding program, if any, if a person in care is involved in a reportable incident; 77( 2 )(d)
  18. Monitoring

    3 infractions

    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Performance evaluations noted as not completed during the last Licensing inspection, since that time RN staff evaluations have been completed. Please submit a plan to Licensing by Dec 19, 2014 identifying how all staff who are overdue for their performance evaluation will have the evaluation completed by April 30, 2015.
      • 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)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Photographs and information by which a PIC may be identified not available for some of the care plans reviewed. Monthly PIC weights documented in different areas, some months Licensing unable to locate during inspection. Ensure weights are documented at least once a month and documented in an area that is accessible to Physicians, Dieticians and staff. Family binder with PIC information stored on handrail, resolved during 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)
      • 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
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): Fall risk plans must include plans for preventing falls as well a plan for following up on falls suffered by a PIC, the fall risk plans reviewed during this inspection consisted of a Scott Fall Risk Assessment which does not give direction regarding fall risk procedures specific to each PIC.
      • 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)