Purcell Place
1906 Kelowna Cres Cranbrook BC V1C 6E5 · Residential Care - Licensing
7 inspections
- Routine Inspection
2 infractions
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): R4.1U - During the review of persons in care records, it is identified that weights for multiple persons in care are not consistently recorded on a monthly basis. Inconsistent recording of weights may result in changes in a person in care’s health status going undetected, potentially impacting the ability to identify and respond to nutritional concerns or other underlying medical conditions in a timely manner. Submit by June 24, 2026, a written plan outlining how the contravention related to ensuring each person in care has a monthly weight recorded has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 83(4)(a)(c) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- R4.1U - 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): R10.3 - During the review of care plans, person in care records, and through discussion with the Manager, it is identified that a person in care who requires a behavioural care plan does not have all aspects of their current plan accurately captured in the care plan. The care plan does not fully reflect the interventions and supports currently implemented by the licensee. Complete documentation of all aspects of care is required to ensure staff have accurate and current information to appropriately guide care and support each person in care’s ongoing health, safety, and dignity. The absence of complete and current documentation in care plans increases the risk that staff do not have clear direction to consistently implement required behavioural supports. This may result in inconsistent care practices, unmet needs, increased safety risks for persons in care and others, and care delivery that does not align with assessed needs or Community Care Licensing requirements. Submit by June 24, 2026, a written plan outlining how the contravention related to care plans including a plan to address behavioural interventions has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 81(3)(a)(ii) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
- R4.1 - Are person in care records current, complete and kept confidential?
- Routine Inspection
1 infraction
- 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): R10.3E - During the review of care plans, it was identified that care plans lacked specific guidance for staff regarding the nutritional needs of persons in care. While care plans referenced nutritional assessments, they did not include the outcomes of those assessments or translate them into clear, actionable guidance for staff. The absence of specific nutritional guidance in care plans may lead to inconsistent care, as staff may miss or misinterpret critical dietary needs. This increases the risk of unmet nutritional requirements, potentially affecting the health and well-being of persons in care. Submit by May 27, 2025, a written plan outlining how the contravention related to nutritional care plans has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 81(3)(c)(i),(ii) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward. R10.3K - During the inspection, it was identified that care plans are not routinely reviewed, and if necessary, updated, in full to ensure they continue to reflect current needs of the individuals in care. In particular, medication care plans lacked documented review dates, making it difficult to determine whether they remain accurate and up to date. Failure to monitor, review and update care plans on a regular basis may compromise staff's ability to meet persons in care's current and individual needs. Submit by May 27, 2025, a written plan outlining how the contravention related to reviewing and updating care plans has been addressed. The plan must also detail the systems and processes that will be implemented to support the review, and if necessary, update of care plans as required by Section 81(4)(b)(i)(ii) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- R10.3E - Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)
- 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)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Routine Inspection
2 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): The system to ensure applied restraints have a written agreement for use by both the person in care or their representatives, and the medical practitioner is ineffective. During a chart audit, it was identified that two persons in care with applied restraints did not have documented written agreements on file.
- R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Routine Inspection
4 infractions
- R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
- Observation(s): The licensee does not currently have a system to provide a planned program of activities within the home.
- 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)
- RB1.13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
- Observation(s): The licensee does not currently have a system to provide a planned program of activities within the home.
- RB1.13A - Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
- 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): During a review of Medication Administration Records, it was identified that a person in care did not have a picture included for identification as per licensee policy. Section85(1)(d) is a re-occurring contravention from the June 22, 2021 inspection.
- 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 system to ensure care plans include an oral health care plan is ineffective. It was noted during the inspection that oral care plans have not been implemented.
- R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
- R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
- Routine Inspection
3 infractions
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): It was noted during the inspection, that the licensee does not have a system for documenting restraint monitoring.
- 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)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): It was noted during the inspection that the effectiveness of as needed medications was inconsistently documented. The system for monitoring compliance with the policies of the medication safety and advisory committee was ineffective. This contravention was also noted out of compliance during the June 2021 inspection. Staffing files were not reviewed during this inspection. Licensing officer will review staff files, as well as the system for maintaining staffing files at the NEXUS office on March 14, 2022.
- R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): The system for ensuring monthly weights are recorded was ineffective. The record of weights was inconsistently documented.
- 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)
- R4.3 - Is documentation concerning restraints adequate?
- Routine Inspection
5 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The system for self monitoring appears to be ineffective. It appeared upon inspection that there is no current system in place for conducting internal audits. It was noted during inspection that temperature monitoring, as well as cleaning records, were missing multiple signatures.
- 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 system for ensuring implementation of policies appears to be ineffective. It was noted during the inspection that multiple policies were not implemented. Policies included restraints policy, mask policy and storage of staff personal belongings.
- 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): As needed medication (PRNs) effectiveness was noted to be inconsistently documented.
- 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): The system for ensuring furniture and equipment is secure appeared to be ineffective. A large picture with glass covering was noted to be leaning against a wall in a living room, and two large utility shelves were noted to not be secured to the wall in the tub room. Contravention related to the picture with glass covering was corrected during inspection. The system for ensuring medicated creams are securely stored appeared to be ineffective. During the inspection medicated cream was noted to be accessible on a nightstand. Program supervisor removed the cream and locked it in the medication cupboard during inspection. Corrected During Inspection
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): It was noted during the inspection that a medication self-administration care plan was not in place. In a random audit of care plans, behavioural interventions were not evident. Daily notes and Medication Administration Records identified behaviours, however, interventions for specific behaviours were not evident in the care plan.
- 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)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection
0 infractions