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Rocky Mountain Care Village

55 Cokato Rd Fernie BC V0B 1M0 · Residential Care - Licensing

13 inspections

  1. Substantiated complaint

    3 infractions

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): RCR 85(1)(d) - The complainant alleges that after staff provided personal care, person in care (PIC) hands were soiled with feces. The complainant also alleges observation of feces on PIC bathroom door and walker. This complaint is substantiated. The complainant document review identifies dried feces on PIC hands, five minutes after receiving personal care. Photo evidence shows brown color on skin and nails of PIC’s left hand. The discoloration of skin and nails is believed to be feces, with no other explanation provided. The Licensee’s communications document states “staff acknowledged the incident, took accountability.” The Licensee's Infection Control & Hand Hygiene Policy states, “resident’s hands will be washed before/after eating, after toileting and when soiled”. In addition, the Licensee's Housekeeping Process includes, “All resident rooms are cleaned daily, with cleaning records maintained”. The PIC room cleaning log documentation did not reflect daily cleaning between the dates of March 1- April 30, 2026. Documentation and photo review provides evidence that the Licensee did not implement policies and procedures to support PIC with hand hygiene and daily room cleaning. When polices and procedures are not implemented, there is risk of PIC receiving care that is detrimental to their health, safety, and dignity. Submit a detailed corrective action plan indicating how the Licensee with ensure that all policies and procedures are implemented, no later than June 26, 2026.
      • 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): RCR 22(1)(c) – As per Licensee’s Housekeeping Services policy, “housekeeping staff are responsible to be aware of and follow schedules for daily, weekly, and monthly routines”. Additionally, the Licensee's Housekeeping Process states “all resident rooms are cleaned daily”. The PIC room cleaning log documentation did not reflect daily cleaning between March 1- April 30, 2026. Substantiated When rooms are not maintained in a safe and clean condition, there is potential for rooms to be unsanitary and have detrimental impacts on the health and safety of PIC. Submit a detailed corrective action plan indicating how the Licensee with ensure that all rooms are maintained in a safe and clean condition, no later than June 26, 2026.
      • 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): RCR 82 - The complainant alleged after staff provided personal care, PIC hands were soiled with feces. This complaint is substantiated. Complainant document review identifies dried feces on PIC hands, five minutes after receiving personal care. Photo evidence shows brown color on skin and nails of PIC’s left hand. The discoloration of skin and nails is believed to be feces, with no other explanation provided. The Licensee’s communications document states “staff acknowledged the incident, took accountability.” The PIC Care Plan Report documents the daily hygiene intervention as “Total Assist” and the incontinence: dementia intervention as “encourage good hand washing”. Photo and documentation review provides evidence the Licensee did not implement care plan interventions to support the hygiene needs of PIC. When care plans are not implemented, there is risk of PIC receiving care that is detrimental to their health, safety, dignity. Submit a detailed corrective action plan indicating how the Licensee with ensure that care plans are implemented, no later than June 26, 2026.
      • 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
  2. Substantiated complaint

    1 infraction

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Allegation: Concerns related to the existing rinsing practices for heavily soiled items, including slings and the personal belongings of persons in care. Evidence of Findings: In observing the dirty utility room, clean mop heads are seen hanging beside a sink that is currently used for rinsing heavily soiled items. The location of the clean mop heads is within an area that may easily be splashed with soiled water. Based on the review of evidence the allegation is SUBSTANTIATED. At the time of this inspection, the clean mop heads are immediately moved to an alternate location that is separate from the dirty utility sink.
      • R7.1AL - Provide separate utility areas that are appropriately furnished and equipped for clean and soiled clothes, bedding and other articles; 35( 1 )(d)
  3. Routine Inspection

    2 infractions

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): During the inspection of the physical facility, a bathroom cupboard was noted to be unlocked and accessible to persons in care. The cupboard contained various bathroom supplies including shaving cream, lotions, and a prescription spray. Access to prescription medications poses several risks to persons in care, especially those who may have cognitive impairments or other vulnerabilities. Submit by May 2, 2025, the plan that will be implemented to ensure ongoing compliance with Section 35(1)(c) of the Residential Care Regulation.
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): During a review of person in care's records, it was identified that one person in care is currently self-administering certain medications. There was no documented evidence the self-administration plan was reviewed and approved by the medication safety and advisory committee, and the medical or nurse practitioner. In addition, the self-administration of medication was not reflected in the individual's care plan. Self-administering medication without proper approval or documentation in the care plan increases the risk of errors, adverse reactions, and has the potential to disrupt proper care management. Submit by May 2, 2025, the plan that will be implemented to ensure ongoing compliance with Section 70(4)(a)(b) of the Residential Care Regulation.
      • 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)
  4. 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): The system to ensure wound care plans were implemented as written is ineffective.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  5. Routine Inspection

    2 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The system to ensure Licensing is notified of manager changes as per legislative requirements is ineffective.
      • R1.1E - Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The system to ensure policies are implemented by staff is ineffective. During a random audit of documentation, it was noted that a staff member had pre-documented a restraint check was completed. This was evidenced by the timestamp on the entry.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  6. Routine Inspection

    3 infractions

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): During a random chart audit it was noted that the system to ensure the post falls observations and assessments were completed as per policy, appeared ineffective.
      • 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): It was noted during the inspection that the system to ensure monthly weights are recorded appeared ineffective.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): It was noted during the inspection that the system to ensure fridge temperatures are monitored to ensure they are within the food safe range appeared ineffective.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  7. Substantiated complaint

    2 infractions

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): During the inspection it was noted that staffing levels were insufficient on one day. It was noted during the inspection that the needs of persons in care, and assistance with activities of daily living were maintained. A health and safety plan for staffing levels was received and approved by Licensing on July 30, 2021.
      • R3.2A - There must be sufficient numbers of trained and experienced employees on duty at all times. Staffing patterns must meet the needs of persons in care and assist persons in care with activities of daily living, including eating, mobility, dressing, grooming and hygiene in a manner consistent with the health, safety and dignity of persons in care; 42( 1 )(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): During the inspection it was noted that the system for ensuring the care and supervision of a person in care is consistent with the care plan was ineffective.
      • 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

    2 infractions

    • 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 spa rooms are in a safe and clean condition prior to use appears to be ineffective. Licensing Officer observed a spa room being prepared for use and disposable razors were accessible. The razors were not labelled as belonging to a person in care and/or marked as being new or used. This issue was corrected during inspection (CDI). Two emergency exit paths were covered in snow. One exit path had both snow and ice accumulated.
      • 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): Wound care plan was not consistently documented in accordance with the identified plan. Missing information related to evidence of assessment or changes to the wound.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  9. Monitoring

    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): Recreation care plans observed during this inspection included assessments that stated person in care's (PIC's) personal goals and activities. The system for tracking implementation appears to be ineffective. Charting is missing details on how PIC's are meeting the goals identified in their plans. Include in your response how this issue will be audited to ensure goals are being met.
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
  10. Monitoring

    5 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): There is a weekly monitoring system in place for TAR documentation. The system appears to be ineffective in that when missed documentation was noted there appeared to be a lack of action. This is a repeated OUTSTANDING INFRACTION.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The system for ensuring that all residents admitted comply with the Province's TB control program is ineffective. LO's noted in a random audit of charts two residents were missing TB screening.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • 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): LO's noted current orientation policy only had DOC and Manager orientated to CCALA and RCR. Orientation checklist adjusted to include all staff. Corrected during inspection (CDI). Non-compliance noted with this section in the complaint review conducted from January 3, 2018 to April 18, 2018. Health and Safety Plan plan pending from complaint inspection report. No additional non-compliance noted during this inspection April 19, 2018.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system for ensuring that all rooms are in good state of repair appeared ineffective. One room was noted to have extensive damage to the washroom door and walls. The system for ensuring hazardous items are appropriately stored appears ineffective. Flammable aerosol spray accessible in shared washroom. (CDI) The system for ensuring medicated ointments are securely stored is ineffective. In a random audit of resident of rooms LO's noted prescription ointments/creams accessible to persons in care.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system for ensuring required information in care plans is ineffective. One resident is being served meal service in their room. In review of the resident's care plan and chart there was no doctor's order or direction in care plan to reflect this. Non-compliance noted with this section in the complaint review conducted from January 3, 2018 to April 18, 2018. Health and Safety Plan plan pending from complaint inspection report. No additional non-compliance noted during this inspection April 19, 2018.
      • 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)
  11. Monitoring

    3 infractions

    • 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): Licensing observed that cleaning agents were left in an unlocked cupboard in the kitchen area and a number of containers of air fresheners were left accessible to Person's in Care (PIC) in the hallways. A housekeeping cart was observed to be left unattended with hazardous cleaning agents left accessible to PIC.
      • RB1.18A - Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Medication Administration Record (MAR) review found inadequate response to PRN effectiveness. Non-compliance with PRN effectiveness has been noted to 3 consecutive inspections.
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing observed that cleaning agents were left in an unlocked cupboard in the kitchen area and a number of containers of air fresheners were left accessible to Person's in Care (PIC) in the hallways. A housekeeping cart was observed to be left unattended with hazardous cleaning agents left accessible to PIC.
  12. Monitoring

    12 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Medication Administration Record (MAR) review found inadequate responses to PRN effectiveness. Non-compliance with PRN effectiveness has been noted on 2 consecutive inspections.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Licensing observed incomplete TB screening in employee records. Non-compliance for employee TB screening has been noted on 2 consecutive inspections.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Licensing observed that the transition from sidewalk to pavement is uneven, creating a safety hazard for falls. Non-compliance with maintaining a safe environment has been noted on 2 consecutive inspections.
      • Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
    • 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): Licensing observed that cleaning agents were left in an unlocked cupboard in a staff room area. Licensing found the storage room door in one neighbourhood was left unlocked, allowing access to persons in care (PIC) to cleaning agents and chemical products. It was noted that the laundry facilities were not locked while staff was not in area.
      • Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • 25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): Licensing observed that there is a process in place to identify PIC who are identified as a risk for aggression and is included on the care plan. The process in place does not address the behavioural interventions on the care plan. Process in place is ineffective to identify and ensure the persons at risk for leaving the facility are identified and an elopement care plan is implemented.
      • Ensure care plans are developed within 30 days.
      • Ensure care plans include all required elements.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing observed ongoing non-compliance in five areas since the previous inspection. Descriptions are in the body of the inspection. Licensee's monitoring of physical environment and the care and services is ineffective.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Medication Administration Record (MAR) review found inadequate responses to PRN effectiveness. Non-compliance with PRN effectiveness has been noted on 2 consecutive inspections.
      • Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing observed an inconsistent recording of monthly weights on persons in care records. Non compliance with weight records has been noted on 2 consecutive inspections.
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): Licensing observed incomplete TB screening in employee records. Non-compliance for employee TB screening has been noted on 2 consecutive inspections.
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing observed inconsistent temperature monitoring of the fridges in the PIC neighbourhoods. Non-compliance to ensure that food is safely stored has been noted on 2 consecutive inspections.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing observed that cleaning agents were left in an unlocked cupboard in a staff room area. Licensing found the storage room door in one neighbourhood was left unlocked, allowing access to persons in care (PIC) to cleaning agents and chemical products It was noted that the laundry facilities were not locked while staff was not in area.
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
      • Ensure that laundry facilities if not used by persons in care, cannot be accessed by persons in care; 35( 2 )(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): Licensing observed that there is a process in place to identify PIC who are identified as a risk for aggression and is included on the care plan. The process in place does not address the behavioural interventions on the care plan. Process in place is ineffective to identify and ensure the persons at risk for leaving the facility are identified and an elopement care plan is implemented.
      • Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • 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)
  13. Monitoring

    9 infractions

    • 3.2 Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): During noon meal, one staff person noted to be supervising two dining areas. Dining areas separated by full wall allowing no sightline from one side to the other.
      • There must be sufficient numbers of trained and experienced employees on duty at all times. Staffing patterns must meet the needs of persons in care and assist persons in care with activities of daily living, including eating, mobility, dressing, grooming and hygiene in a manner consistent with the health, safety and dignity of persons in care; 42( 1 )(a)(b) (Show More)
    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Inconsistent recording of reason and effectiveness of "as needed" (PRN) medications on multiple person in care records.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Unable to locate evidence of tuberculosis screening on one staff file.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Unable to locate certificate of First Aid completion on staff file.
      • 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)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Unable to locate admission height/weight on multiple person in care files. Unable to locate physical description of person in care on multiple person in care files.
      • 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)
    • 4.6 Are facility records current and complete?
      • Observation(s): Unable to locate record of complaints. Complaint file is kept but does not include log of actions/responses and dates of same.
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Snacks do not consistently include items from 2 food groups.
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Unable to locate temperature monitoring on multiple food fridges.
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Outdoor paved patio has raised screws with loose cover, posing risk for tripping. Transition point from patio area path to entry way is uneven, posing risk for falls. Cigarette butts noted on patio. Staff deny knowledge of any persons in care smoking in this area. Inadequate monitoring of medication temperature fridges. Only 2 data entries noted for August.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Ensure that no one other than a person in care smokes while on the premises; 23(a)
      • Ensure all medications are safely and securely stored; 69( 3 )(a)