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Ridgewood Lodge

98 Ridgewood Dr Princeton BC V0X 1W0 · Residential Care - Licensing

12 inspections

  1. Routine Inspection

    1 infraction

    • 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): Several Medication Administration Records reviewed; in which PRN(as needed) medication effectiveness is not documented. If staff are not able verify whether the PRN medication was effective or not, this can lead to compromised safety and wellbeing of persons in care. 1 chart reviewed that has a restraint agreement, however restraint monitoring documentation is incomplete/missing for several dates. Incomplete restraint monitoring documentation can result in unsafe practices and possible injury posing serious risk to persons in care. Please submit a corrective action plan by June 19 , 2026, advising how all current and future restraint monitoring /medication administration documentation will be completed in an accurate, timely and efficient manner.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  2. Routine Inspection

    4 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): A chart did not contain a restraint care plan. If there isn't a restraint care plan, it can increase the risk of the restraint not being used properly or as required. Submit an action plan by June 23, 2025, detailing how all persons in care will have a restraint care plan as required, including a system for monitoring ongoing compliance with the Residential Care Regulation.
      • 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 restraint monitoring form showed evidence of staff not properly documenting or conducting restraint applications, removal, or safety checks at as per the site policies. Staff not following policies pertaining to restraint monitoring can increase the person in care's risk for falls or choking. Submit an action plan by June 23, 2025, which indicates how staff will properly and consistently follow the restraint monitoring policies. Three fire extinguishers were not checked monthly by facility staff contrary to the site policies. If the policies are not followed by staff, it can increase the risk of the equipment not operating as intended. Submit an action plan by June 23, 2025, detailing how staff will conduct and document fire extinguisher checks as required per site policy. Reviewed three Medication Administration Records (MAR) for persons in care, each contained multiple examples of the effectiveness not being charted as per policy for the Pro Re Nata (PRN) medications; also called as needed medications. Charting for 13 PRN medications were reviewed, 8 of which were not charted as per policy. If the PRN medications are not properly charted for effectiveness, this can increase the risk of incorrect dosages, amounts, and medications used to properly manage medical conditions or symptoms. Submit an action plan by June 23, 2025, outlining how staff will document and monitor the PRN medication effectiveness, including how site leadership will monitor the plan for its effectiveness.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): An open hatch providing access to the fire suppression system valve was accessible to persons in care. If the fire suppression valve was accessed and turned off, it could render the system ineffective. The hatch was immediately closed and locked by staff. A monitoring plan was also added to the daily inspections by staff. The plan was accepted and this contravention under Residential Care Regulation 22(1)(c) has been resolved. An emergency door would not properly close and lock. This could result in persons in care eloping from the facility undetected by staff. An immediate Health and Safety Plan was requested to mitigate this immediate risk; the plan was received the same day, June 3, 2025. The plan will remain in place until the door has been properly repaired and the contravention under Residential Care Regulation 22(1)(c) is resolved. Licensing Officer observed two bedrooms containing uncovered baseboard heaters . A person in care may be injured if they reach into the uncovered heater. Submit an action plan by June 23, 2025, ensuring all baseboard heaters are properly covered and monitored as per Residential Care Regulation 22(1)(b), ensuring the safety of persons in care. A cupboard accessible to persons in care was not properly secured and contained dishwashing soap. This could increase the risk of a person in care ingesting the soap or spilling soap on the floor, therefore increasing the risk of a fall. Submit an action plan by June 23, 2025, detailing how staff will ensure the proper storage of cleaning agents.
      • 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)
      • R7.1AK- 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): Reviewed 3 persons in care's charts which contained outdated care plans with no indication they were outdated. If a chart contains an outdated care plan, it can increase the risk of a staff member following an outdated care plan which may cause them to not provide the most current care practices. Submit an action plan by June 23, 2025, detailing a system to mitigate this risk and ensure staff will always follow the most current 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
  3. Routine Inspection Follow-up

    1 infraction

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The licensee operates a temporary Adult Day Program (ADP) at the facility. The licensee and facility staff have confirmed that there are times when facility capacity has been exceeded during program operation. The licensee intent is to move the ADP offsite with an external provider operating the program. The facility Licensing Officers (FLO) have provided education and information to assist the licensee to ensure compliance. To this date, the facility is still not in compliance. The chronology is as follows: - discussion during routine inspection October 11, 2024 - email to manager October 16, 2024 - phone call and follow-up email with director October 18, 2024 *An incomplete exemption request was received from the director on October 28, 2024. - an email requesting a complete request was sent to the Director on October 29, 2024; email response on November 11, 2024 from Director acknowledging gaps and stating that external program provider for the ADP was being sourced. -November 19, 2024, TEAMS message from Director to Licensing Officer advising that exemption request would be submitted by the end of business day. - November 22, 2024 - FLO spoke with facility long term coordinator regarding capacity limits and affect of ADP and the pending exemption request. - December 10, 2024, FLO met with recreation coordinator to discuss ADP and confirmed that facility was within its capacities that day. - December 11, 2024 FLO sent email to manager and director providing continued information regarding the Regulation along with questions regarding facility and ADP operation. - December 13, 2024 Director provided email to FLO responding to questions, including the following information: 1) Confirmed that when ADP operates, facility is overcapacity. 2) Confirmed that there was no end date for the ADP to leave the facility. 3) Confirmed that the exemption request would be submitted to Licensing. - January 17, 2025 new FLO met virtually with the director for an introduction. FLO queried status of exemption request and director advised that exemption request was forthcoming. - February 19, 2025 confirmed with facility staff that facility was at capacity and the ADP was still operating, confirming non-compliance and overcapacity. - February 20, 2025 FLO emailed Director for exemption update and provided template for request. - March 6, 2025 Director emailed FLO advising that there may be a successful proponent for ADP and querying whether exemption request was still required; FLO responded confirming that a complete request was still required to ensure compliance.
      • R1.1U - Accommodate only the number of persons in care specified on the licence; 46( 2 )(b)
  4. Routine Inspection

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing Officer did not observe an effective monitoring system ensuring the physical environment was in compliance with the Residential Care Regulation (RCR). There were 12 physical environment related contraventions noted in this 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): Licensing Officer observed a fan and a box of masks blocking hand rails within the facility, this was contrary to facility policy. Licensing Officer observed a refrigerator where the daily temperatures were not being recorded as per policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing Officer observed an electrical chord hanging in a dining room without a purpose, presenting a potential hazard to persons in care. This was corrected during the inspection. Licensing Officer observed both an uncovered baseboard heater and an uncovered air conditioning unit in a dining area. These were corrected during the inspection. Licensing Officer observed gardening tools in the outdoor area which were not securely stored. This was corrected during the inspection. Licensing Officer observed an open electrical box in an outdoor area, accessible to persons in care. This was corrected during the inspection. Licensing Officer observed a plastic storage bin full of standing water in an outdoor area, accessible to persons in care. This was corrected during the inspection. Licensing Officer observed two trap doors on facility floors, accessible to persons in care, and when opened led to a significant drop into a crawl space. Licensing Officer observed a nursing office which contained records of persons in care. The nursing office was accessible through a courtyard used by persons in care, therefore not providing safe and secure storage. Licensing Officer also observed an open and unattended employee office containing records of persons in care. Licensing Officer observed a set of wrenches stored in a kiosk, which were not safely and securely stored. Licensing Officer observed an unattended medication cart which was not locked, containing medications accessible to persons in care. A corrective action plan for this contravention has been requested for October 21, 2024.
      • 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)
      • R7.1AJ - Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 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)
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
  5. Routine Inspection Follow-up

    2 infractions

    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): During the investigation, the Licensing Officer reviewed evidence showing personal information was not kept confidential by a staff member.
      • R4.1V - Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • R4.6 - Are facility records current and complete?
      • Observation(s): During the investigation, the Licensing Officer reviewed complaint records which did not include the required responses as per the Regulation.
      • R4.6F - Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
  6. Substantiated complaint

    2 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Allegation – The Licensee is in non-compliance with Residential Care Regulation (RCR) 77(2)(a). The allegation was investigated through information received from the complainant, the review of confidentially submitted documentation, and correspondence with the licensee contacts. As a result, licensing found evidence the parent, representative or contact person was not immediately notified after a reportable incident. The allegation that the Licensee is in non-compliance with RCR 77(2)(a) is substantiated. The contravention has been resolved as per the accepted June 21, 2024, corrective action plan.
      • R4.5B - Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77( 2 )(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): Allegation – The Licensee is in non-compliance with Residential Care Regulation (RCR) 85(1)(d). The allegation was investigated through information received from the complainant, the review of confidentially submitted documentation, and correspondence with the licensee contacts. As a result, licensing found evidence that policies/procedures regarding documentation and notifications were not followed. The allegation that the Licensee is in non-compliance with RCR 85(1)(d) is substantiated. The contravention has been resolved as per the accepted June 21, 2024, corrective action plan.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  7. Routine Inspection

    4 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): The system to ensure that equipment for use by persons in care is maintained in a safe and clean condition is ineffective. A basket of several unlabeled nail clippers was observed in the "A" side building tub room. All other personal care items were kept separated, in labeled baskets, for personal use.
      • R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The system to ensure that policies are implemented by employees is ineffective, as described by the following: It was observed during inspection that there were several instances on Medication Administration Records where signatures were missing. *This is an ongoing contravention. It was observed during inspection that there were several instances where PRN effectiveness documentation was missing. *This is an ongoing contravention. It was observed during inspection that several monthly fire drills were missing over a twelve month period, as evidenced by the months of January, June, July, and August of 2023, and January of 2024, being completed. *This is an ongoing contravention.
      • 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 that a record is kept for each person showing information by which the person in care may be described or identified in an emergency is ineffective. It was observed during inspection that two persons in care's charts were missing hair and eye colour identifiers.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system to ensure that water accessible to persons in care does not exceed 49 degrees Celsius is ineffective. During an audit of hot water temperatures, in the "B" side building, the hot water temperature in the respite room read 54.2 degrees Celsius, and the hot water temperature in the kitchen read 55.6 degrees Celsius. The system to ensure that hazardous materials are stored securely is ineffective. It was observed during inspection that an alarmed but unlocked door leading to the "A" side kitchen, which contains hazardous materials, was accessible to persons in care.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • 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)
  8. Routine Inspection

    5 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Licensing officer observed a person in care's chart that did not contain a restraint agreement in writing as required by the Regulation.
      • R2.2B - Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73( 2 ); 75( 2 )(a)(i)(ii)(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): Licensing officer observed three persons in care's charts, each of which were missing signatures on the medication administration record. Licensing officer observed three persons in care's charts, each of which were missing the documented effectiveness for administered PRN medications. Licensing officer was informed during the inspection that the monthly fire drills had not been completed as per facility policy. Licensing officer observed a fridge in the medication room where the temperature was not being monitored as per facility policy. Licensing Officer observed three charts for persons in care, each had an incomplete admission and separation form, two had an incomplete chard audit form, two had an incomplete admission checklist form, and all three had an incomplete section on immunization screening. All of these incomplete documents are contrary to facility policy. Licensing officer observed that new staff were not being orientated to the Residential Care Regulation and the Community Care and Assisted Living Act contrary to the Regulation.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing officer observed the documentation pertaining to the monthly weights of persons in care, there were various missing weights on the documentation.
      • 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): Licensing officer observed the snack menu for the week. There were two instances where two food groups were not provided.
      • 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)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Licensing officer observed a care plan that was not reviewed or revised after a substantial change in the circumstances of the person in care. Licensing officer observed three persons in care's charts, two did not contain oral care plans. Licensing officer observed three persons in care's charts, one did not contain a recreation care plan.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  9. Routine Inspection

    6 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): There are four bedrooms that are directly accessible from a lounge/recreation area. According to Residential Care Regulation Section 26 (2) bedrooms are to be directly accessible from a hallway. The large shelves used to designate hallways have been moved from their previous location.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • RB1.10 - Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
      • Observation(s): See question R10.2 that has been noted on this report.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): - An employee responsible for taking persons in care for off site activities does not hold a valid first aid/CPR certificate. - The effectiveness of PRN’s are not consistently recorded.
      • 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)
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): - Unlabelled nail clipper, scissor, hair brushes and various curling irons were found in both tub rooms. - Refrigerators located in bedrooms are not being monitored.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It is reported that the last family and resident council was conducted over a year ago. The council date is unknown at this time.
      • R10.2R - Provide at least an annual opportunity for persons in care and their parents or representatives, family members and contact persons to establish councils or similar organizations to represent the interests of persons in care; 59(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): Care plans and room ADL (Activities of Daily Living) forms have limited information to guide care staff on each persons oral health care needs.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  10. Monitoring

    1 infraction

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Upon review of the incident report binder, the Licensing Officer discovered an incident only reported internally that should have been reported to Licensing and wasn't. The Manager indicated this would be submitted immediately.
  11. Monitoring

    3 infractions

    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Multiple person in care's care plans did not indicate the height and weight upon admission. This is a recurring infraction (noted on inspection report dated February 25, 2016).
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Hot water temperature tested in multiple locations throughout the facility and measured to be between 55 and 56 degrees Celsius.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee provides ongoing meal tray services for a few persons in care; however, the Licensing Officer unable to locate this information (plan, safety considerations, reassessment) on the person in care's care plan or chart. This is a recurring infraction (also noted on inspection report of February 25, 2016).
      • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
  12. Monitoring

    6 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Person in care's restraint care plan was observed to be missing written consent by person in care or their representative.
      • 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)
    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): On medication administration records and in nurse progress notes, the effectiveness for PRN (as needed) medication administration is not being recorded consistently.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Multiple person in care's care plans missing TB and immunization information.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Multiple person in care's care plans missing height and weight of person upon admission. Multiple person in care's care plans missing information that can be used to identify them in case of emergency.
      • Record the height and weight of each person in care on admission; 49 ( 2 )
      • 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)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It was observed that there are broken and cracked wall tiles in one bathing room. In one person in care's room, it was noted a baseboard heater cover has been damaged (bent edges and badly dented).
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Person in care who receive some or all of their meals with ongoing tray service missing reassessment records on their care plans as required.
      • Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)