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Silver Kettle Village

2350 72 Ave Grand Forks BC V0H 1H4 · Residential Care - Licensing

9 inspections

  1. Routine Inspection

    0 infractions

  2. Substantiated complaint

    3 infractions

    • RB1.12 - Are persons in care prevented from being punished by abuse, neglect or the deprivation of foods or fluids?
      • Observation(s): Please see findings connected to Section 52 contravention.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): It was determined that the involved staff did not demonstrate the necessary competence to ensure the health, safety and dignity of persons in care. Licensing and the licensee contact interviewed 13 staff who provided evidence which indicated that the involved staff did not perform care using a person-centered and gentle persuasive approach.
      • R3.1O - Ensure employees have the necessary training and experience or demonstrate the necessary competence to carry out duties; 40 ( 3 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It was determined that the involved staff engaged in actions which meet the definition of physical and emotional abuse. Allegations outlined the involved staff's approach and care which was described as rough and rushed, and speaking to Persons in Care (PIC's) with a demeaning and loud tone. It was alleged that PIC's were afraid of the involved staff. Additionally it was alleged that the involved staff used excessive force with PIC's when providing care. The involved staff provided inconsistent accounts of alleged incidents. Licensing and the licensee contact interviewed 13 staff who provided evidence including witness statements which supported the allegations, which included slapping a PIC's hand, restraining a PIC, waking up a PIC using cold water and shouting at a PIC. On a balance of probability, the allegations have been substantiated.
      • R10.2D - Ensure persons in care are not subjected to financial, emotional, physical, sexual abuse or neglect; 52( 1 )(a)
  3. Substantiated complaint

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The licensee did not report the service delivery issue (missed baths due to staffing shortage) to Licensing 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The system to monitor call bell responses, bath scheduling and room maintenance is ineffective.
      • 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): Staff did not follow policies and procedures regarding communicating maintenance concerns and performing call bell response. Staff did not follow best practices regarding communication with the person in care.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): It was confirmed that a Person in Care missed a weekly bath due to staffing issues. It was confirmed that staff provided personal care to person in care, however this did not replace the full weekly bath that the person in care required.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Concerns were expressed regarding call bell response. A review of facility call bell logs confirmed that a Person in Care's call bell was not answered for approximately18 minutes. This delay exceeded the facility's best practices guidelines.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  4. Routine Inspection

    1 infraction

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Water temperature measured at two different taps exceeded 49 degrees.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
  5. Routine Inspection

    2 infractions

    • R4.6 - Are facility records current and complete?
      • Observation(s): There was not a menu substitution list and it was confirmed that some menu items were being substituted if they were were not available from the supplier (for example a different type of fish).
      • R4.6C - Retain food services records of menus and menu substitutions; 87(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Noticeable wear to areas of dining room walls and person in care bedroom walls due to wheelchair/walker use.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  6. Routine Inspection

    2 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): In a review of resident records, it was identified that there continues to be a lack of a system to ensure persons in care have an immunization status on file. This contravention was also identified during the last routine inspection.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It was noted during the inspection that the system to ensure the records of persons in care, as well as medications, were not consistently secured. It was noted that the doors to the room were left open while no staff were present.
      • 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)
  7. Monitoring

    4 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): In a review of resident records, LO noted that there was lack of system to ensure persons in care have an immunization status on file.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
      • R6.2B - Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • RB1.25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): In a random audit of care plans, LO noted that not all resident's have an oral care plan in place. - see R 10.3 above.
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Lo noted a bag of 6 disposable razors in one person in care's room which were accessible. Please inform licensing of the system which will be implemented to ensure that all hazardous items are safely stored.
      • 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): In a random audit of care plans, LO noted that not all resident's have an oral care plan in place. One person in care's shared risk agreement had not been reassessed/reviewed within the past year.
  8. Monitoring

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The current system for monitoring temperatures in resident rooms does not appear to be effective. The audit tool reviewed was not consistently being completed.
      • 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 the policies and procedures are reviewed/revised at minimum annually appears ineffective. Upon a random audit of the policies listed in section 85 of the residential care regulation (RCR) LO noted the the policy for reporting incidents was last reviewed in 2013. In addition, the policy did not include all of the reportable incidents as defined in Schedule D of the RCR.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system for ensuring performance reviews are conducted as per the Golden Life policy appears to be ineffective. Upon a random audit of staff files, one employee had not had a review conducted since 2014. Please inform licensing of the system you will implement to ensure compliance in this area moving forward.
      • 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): In a random audit of the 'family binders', LO noted that the system of ensuring all care plans are reviewed/revised annually is ineffective. One resident had a typed up care plan (in addition to the MDS care plan) guiding staff on approaches and consistency of care provision which was last reviewed in September of 2015.
  9. Monitoring

    5 infractions

    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Upon a random audit of employee files, one file did not show continued (or any) evidence of compliance with the Province's immunization program.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): All charts audited were noted to have TB screening completed, however, LO could not see any evidence of the resident's "immunization status" in accordance with the Province's immunization program.
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The effectiveness of PRN medication is not being consistently recorded as required by the medication administration policy.
      • Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): Upon a random audit of employee records, one record did not have evidence of compliance with the Province's immunization program.
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The temperature readings are not consistently being recorded for the medication fridge.
      • Ensure all medications are safely and securely stored; 69( 3 )(a)