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Spartan Place

5393 Spartan Rd Vernon BC V1B 3K9 · Residential Care - Licensing

10 inspections

  1. Routine Inspection

    0 infractions

  2. Routine Inspection

    0 infractions

  3. Routine Inspection

    0 infractions

  4. Routine Inspection

    0 infractions

  5. Routine Inspection

    0 infractions

  6. Monitoring

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system in place for ensuring criminal record checks are obtained is ineffective. It was discussed and noted during the inspection one staff record was missing a copy of the criminal record check. This remains outstanding from the previous inspection report. There was a copy of the "sharing" application in the file.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
  7. Monitoring

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system in place for ensuring compliance with staff records is ineffective. A criminal record check was not on file for one staff member out of the three staff records reviewed. An expired first aid certificate was noted for one staff member out of the three staff records reviewed.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • 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)
  8. Monitoring

    7 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Missed signatures noted on the Medication Administration Record for several scheduled medications.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): From the spreadsheet and the sampling of staff records reviewed, it was noted that one staff has an overdue performance evaluation. This remains outstanding from previous inspections.
      • 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): Weights were not recorded one one person in care for November and December of 2015. Weights were retrieved from filed documentation and recorded during the inspection. This item was corrected during the inspection.
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 4.6 Are facility records current and complete?
      • Observation(s): Menu substitutions were noted on the menu plan but were not recorded on the menu substitution log.
      • Retain food services records of menus and menu substitutions; 87(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Refrigerator temperature logs completed on a daily basis. The log indicated the fridge temperatures were above the preferred temperature range of 4 degrees Celsius with another increase of temperature noted for the past 6 days without any corrective measures implemented.
      • 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): Spackle from the ceiling in the downstairs bathroom was noted to be falling off in several areas. This remains outstanding from the past inspection. There was a hole in the hallway wall by the downstairs bathroom. Paint chipping on the trim of the stairwell railing.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(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): Care plans for all persons in care have not been reviewed since November of 2014. Behaviour support plans have not been reviewed for over 1 year. Review sheets in the person in care records indicated that the oral care plan has not been reviewed for over one year. This item was noted on the past inspection report. This was reviewed by the manager and corrected during the inspection.
      • 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. Monitoring

    6 infractions

    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): A sampling of staff records were reviewed and two staff records were missing immunization records and one staff record was missing a tuberculosis screen. This infraction remains outstanding from the past inspection report.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 5 )
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): A sampling of staff records were reviewed and several of the records did not include performance evaluations. The facility policy indicates that employee appraisals are to be completed annually. The manager has started to complete the evaluations but this infraction remains outstanding from the last inspection.
      • 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): A sampling of person in care records were reviewed and a consent to call the medical or nurse practitioner or ambulance was missing from one record of a person in care. A sampling of person in care records were reviewed and monthly weights were not recorded for several months on one persons in care record.
      • Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Spackle from the ceiling in the downstairs bathroom was noted to be falling off in several areas. Carpet on the stairway noted to be stained and worn. Mirror in one of the bathrooms upstairs was missing as well as damage to the bathroom wall. Cement by garden shed noted to be settling with uneven edges posing a safety risk to persons in care.
      • 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)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): There were no recent Medication Safety Advisory Committee meetings available during the inspection. The last minutes on file were from several years ago.
      • 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)
    • 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): Review sheets in the person in care records indicated that oral care plans have not been reviewed for over one year.
      • 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)
  10. Monitoring

    14 infractions

    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Immunization and tuberculosis screening was not on record for one staff member and influenza immunization records were not file for several staff members. Influenza signage was not posted in the facility and the manager was not aware of the names of the staff not immunized who are required to wear the face masks during the influenza season from Dec. 1 - March 31.
      • 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): Influenza records were not in the records of the persons in care. Influenza records were obtained from the pharmacy and placed in the person in care records during the inspection.
    • 8.1 Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Limited ongoing planned program of physical, social and recreational activities noted on the activity calendar. Planned activities provided by the home were noted for evenings. There was a sheet available for those persons in care who attend day programs but not all persons in care attend day programs on a daily basis. This was noted as comments during the last routine inspection but has not been followed up on.
      • 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)
    • 8.2 Does the program of activities support individualized care plan requirements?
      • Observation(s): Limited ongoing programs noted on activity calendar.
      • Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55(1)(a)(ii)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Several infractions were noted during the inspection and there continues to be several outstanding infractions noted from previous inspections. Monthly fire drills were missed on several occasions, fridge temperature logs were not being completed on a daily basis, program calendar was not updated as per discussion from the last inspection, menu plan not reviewed. As per section 61 of the Residential Care Regulation: " A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met."
      • Regularly monitor the physical environment and the care and services provided; 61
    • 13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): Limited ongoing planed activities noted on the activity calendar. This is also noted in the inspection report.
    • 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): Emergency manual had the previous manager listed as a contact on the emergency contact sheet. Reportable incident policy did no include "aggression between persons in care".
      • Update emergency plans if there is any change in the facility; 51 (2)
      • Review and, if necessary, revise policies and procedures at least once a year; 85(1)(b)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): A sampling of staff records were reviewed during the inspection and one staff record did not have any reference checks, immunization or tuberculosis screening or first aid certification. (TB screening, reference checks and first aid outstanding from previous inspection report) Several staff records did not have copies of influenza immunization on file. Performance reviews for several staff members are overdue and have not taken place for several years. Fire drills have not been conducted on a monthly basis. Drills were not recorded for several months over the last year.
      • Obtain character references for all employed persons; 37(1)(b)
      • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37(1)(e)
      • 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)
      • 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)
      • Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 (3)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Monthly weights were not recorded in the person in care records for 2015. (recording of weights in records was outstanding from previous inspection report) This was corrected during the inspection.
      • 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): Reference checks were missing from one staff record. Immunization and tuberculosis screening missing from one staff record. Influenza immunization records missing from several staff records.
      • Keep employee character references; 86(b)
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
    • 4.6 Are facility records current and complete?
      • Observation(s): Records of family and resident council meetings were not being completed by the facility.
      • Retain records of compliance with family and resident council required in section 59; 89(2)(b)
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Snack menu was incomplete and did not contain two snacks per day with at least 2 food groups described in the Canada's Food Guide.
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62(2)( c)(i)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Refrigerator temperature logs were not being kept up on a daily basis. Temperatures were missed being taken since the beginning of March as well as only 50% documented on the February temperature sheet left on file. (this remains outstanding from the previous inspection)
      • 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): There is no record on file for several years that a fire inspection or sprinkler system has been checked. BBQ located on deck outside did not have a cover on it and knobs for the gas accessible to persons in care.
      • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 (3)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35(1)(c)