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Spring Valley Care Centre

355 Terai Ct Kelowna BC V1X 5X6 · Residential Care - Licensing

12 inspections

  1. Routine Inspection

    3 infractions

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): February 19, 2026 The Licensee does not have a system in place to ensure the posted menu includes for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada’s Food Guide. During the last routine inspection, it was discussed that some snacks were listed as baked goods and milk. The Manager reported at that time that there would be a reassessment of the offered snacks. It is noted that the posted snack menu still lists some snacks as baked goods and milk. When the posted menu does not list snacks as per the minimum standard stated in the legislation there may be risk to the health and/or dignity of the persons in care. The Licensee will submit a Compliance Plan by March 12, 2026 outlining the system that will be put into place to ensure the posted menu lists snacks in compliance with the legislation.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): February 19, 2026 The Licensee does not have a system in place to ensure that all persons in care are offered a safe, secure place in which the person in care may store valuable property at no cost to them. When all persons in care are not offered a safe, secure place to store what may be valuable to them as per the minimum standard stated in the legislation, there may be a risk to the dignity of the persons in care. The Licensee will submit a Compliance Plan by March 12, 2026 outlining the system that will be put into place to ensure that a safe, secure storage place is offered to all persons in care in compliance with the legislation. The Licensee does not have a system in place to ensure that persons in care are prevented from accessing potentially hazardous materials. It is noted that a cupboard containing employee’s personal bags is unlocked and accessible to persons in care. When all persons in care are not prevented from accessing potentially hazardous materials as per the minimum standard stated in the legislation, there may be a risk to the health and safety of persons in care. The Licensee will submit a Compliance Plan by March 12, 2026 outlining the system that will be put into place to ensure that persons in care are unable to access potentially hazardous materials in compliance with the legislation.
      • R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 1 ) (a)
      • 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): February 19, 2026 The Licensee does not have a system in place to ensure that all requirements of the legislation are included in all persons in care’s care plans. It is noted that of 5 care plans reviewed 1 is missing an oral care plan and 1 is missing a recreation care plan. When care plans are missing required directives as per the minimum standard stated in the legislation there is a risk that employees may not provide the required care which may negatively impact the health, safety and/or dignity of the persons in care. The Licensee will submit a Compliance Plan by March 12, 2026 outlining the system that will be put into place to ensure that all care plans for all persons in care are in compliance with the legislation.
      • 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)
  2. Routine Inspection

    0 infractions

  3. Routine Inspection

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): June 14, 2022 Contravention - The Licensee’s system to ensure that reportable incidents are submitted immediately and/or contain all of the required information is ineffective.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): June 14, 2022 Contravention - The Licensee does not have a system in place to ensure that the weekly menu is posted in a prominent place in each dining area. The Site Leader reported during the inspection that the font size of the menu will be enlarged for easier reading, and that they will ensure that the menus are posted prominently in each dining area. The Licensee has an exemption in place for RCR 30(a) – a bathroom door, equipped with a lock that can be opened from the outside in the case of an emergency. The facility has a system in place for assessing, obtaining consent and tracking; this system will be reviewed for compliance during a future inspection. The Licensee has a system in place to monitor the physical environment for compliance. Housekeeping audits and the Preventive Maintenance Calendar were reviewed by Licensing. A walk-about was conducted during the inspection. The Licensee’s system was found to be effective.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): June 14, 2022 Contravention - The Licensee does not have a system in place to ensure that if a person in care may leave the facility without notifying an employee, and may not be capable of identifying themselves, be fitted with a bracelet or other means that cannot be removed easily, containing their emergency contact information.
      • R10.2M - Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56( 3 )(a)(b) (Show More)
  4. Routine Inspection

    0 infractions

  5. Routine Inspection

    8 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): July 31, 2019 5.) The Licensee's system to ensure that the facility is compliant with incident reporting, and compliant with Health and Safety Plans and Compliance Plans is ineffective. The facility has submitted three Plans upon the request of Licensing to ensure compliance with section 77, and during this inspection three high risk incidents of aggression between persons in care that occurred between the end of April 2019 and the inspection date were located by Licensing, and noted to not have been reported to Licensing. Licensing requested that the three reportable incidents be submitted.
      • R4.5B - Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77( 2 )(a)
      • R4.5C - Immediately notify the medical or nurse practitioner responsible for the person in care involved in a reportable incident; 77( 2 )(b)
      • 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)
      • R4.5E - Immediately notify the funding program, if any, if a person in care is involved in a reportable incident; 77( 2 )(d)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): July 31, 2019 1.) The Licensee's system for monitoring the physical environment and the care and services provided for compliance is ineffective as indicated by the contraventions in this report.
      • 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): July 31, 2019 2.) The Licensee's system for ensuring ongoing compliance with Compliance Plans submitted to Licensing is ineffective. It was noted during the inspection that a supply cart was parked in a person in care's room and the person in care was not receiving care at that time. This action is in contrast with facility policies and procedures and was contravened in a routine inspection conducted on October 24, 2016. 3.) The Licensee's auditing system to ensure compliance with facility processes is ineffective. During the inspection it was noted that two persons in care with responsive behaviours were not included in the facility's Responsive Behaviour Team binder for care review and monitoring.
      • 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): July 31, 2019 4.) The Licensee's facility system to ensure that care plans are developed in accordance with the legislation is ineffective. One person in care had been admitted 53 days prior to the date of inspection. During a review of their chart it was noted that they did not have a care plan in place that was in accordance with the legislation. The facility reported that they were aware that care plans in general were not up-to-date however a plan had not been put into place to come into compliance.
      • R4.1Q - Ensure a care plan is developed within 30 days for persons in care admitted for more than 30 days; 81.1; Director of Licensing Standards of Practice: Advance Directives and Care Plans
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): July 31, 2019 6.) The Licensee does not have a facility system in place to ensure that food is safely stored for the persons in care who have personal fridges in their rooms.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): July 31, 2019 7.) The Licensee's system for ensuring ongoing compliance with Compliance Plans submitted to Licensing is ineffective. It was noted during the inspection that water was pooling in the centre of the floor on the second floor patio posing a slipping hazard. This was previously observed by Licensing and contravened in an inspection report on May 15, 2015. 8.) The Licensee's system to ensure compliance with the posting of menus is ineffective. It was noted during the inspection that a weekly menu was not posted in every dining room and/or in a prominent place. The Manager reported that the font size for the posted weekly menus will be increased.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): July 31, 2019 9.) The Licensee's system to ensure that care plans are developed in accordance with the legislation is ineffective. During the inspection it was noted that a person in care was being provided with ongoing room tray service without physician's orders, and the care plan did not contain a plan to reassess at least once every 30 days. This was previously contravened during a June 13, 2018 complaint inspection.
      • 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)
    • 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): July 31, 2019 10.) The Licensee's system to ensure that 30 minute checks are conducted as per the care plan is ineffective. It was noted during the inspection that a person in care on 30 minute safety checks had been signed off as being checked every 30 minutes until 5:00 p.m. on July 31, 2019 however, the check list was audited at 2:30 p.m. of that day.
      • 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
  6. Routine Inspection

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): December 21, 2018 The facility's system for monitoring Plans that have been put into place to ensure compliance with section 77(2) is ineffective. It is noted that Plans put into place in July 2017, October 2018, and December 2018 failed to ensure that reportable incidents were reported immediately, and/or completely, and/or with correct incident types, and/or facility actions - corrective measures to mitigate future risk. Please submit a Compliance Plan that will outline the system that will be put into place and the education that will be provided to ensure compliance with section 77(2), the plan for continued education of current and new staff, and who will monitor the system and when to ensure ongoing compliance.
      • 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)
    • R6.1 - Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): December 21, 2018 The facility does not have a system in place to ensure that staff are compliant with the Province's immunization control program as it pertains to the prevention of influenza. Please submit a Compliance Plan that will outline the system that will be put into place to come into compliance, and who will monitor the system and when to ensure ongoing compliance.
      • R6.1A - Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): December 21, 2018 During the inspection it was identified that the facility does not have systems in place to ensure staff compliance with the facility policy for influenza management and prevention, ensure ongoing compliance with incident reporting, ensure that care plans have complete information on both the care plan and the section of the care plan that guides the direct care providers, and ensuring that follow-up/monitoring for responsive behaviour is conducted and documented. Please submit a Compliance Plan that will outline the systems that will be put into place to come into compliance with the above four sections, and who will monitor the systems and when to ensure ongoing compliance.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): December 21, 2018 A staff member reported to Licensing that they had reported an incident of responsive behaviour to the LPN on duty, and documentation was not in place to indicate that follow-up, intervention, and monitoring had been conducted. Please submit a Compliance Plan that will outline the system that will be put into place to come into compliance with the regular monitoring of the health and safety of each person in care, and who will monitor the system and when to ensure ongoing compliance.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
    • 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): December 21, 2018 A care plan was observed to contain a specific directive for a person in care, and this directive was not included in the section of the care plan that is used to guide the direct care providers, thus this directive would have been unable to be implemented by those providing direct care. Please submit a Compliance Plan that will outline the system that will be put into place to ensure that all person in care specific directives are included in all sections of the care plans, and who will monitor the system and when to ensure ongoing compliance.
      • 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
  7. Monitoring

    1 infraction

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): June 20, 2017 -The facility does not have a system in place to ensure that licensing or the contact person is notified immediately if a person in care is involved in a reportable incident. Incident reports were reviewed and it was noted that from April 7th to June 16th 2017 there were 24 incidents reported to licensing and 7 (approximately 29%) were reported late. It was also discussed that some incident reports contained incorrect dates of birth, were missing information, and in one case a family was not notified of a fall until 14 hours after the incident.
      • R4.5B - Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77( 2 )(a)
      • 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)
  8. Monitoring

    3 infractions

    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Oct. 24, 2016 - The facility's system for ensuring compliance with the monitoring of resident status changes to ensure that they are followed up on was noted to be ineffective in 2 of the 3 charts that were audited.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 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): Oct. 24, 2016 -The facility's system for ensuring staff compliance with procedures was noted to be ineffective. It was noted that an electric portable fan was in a resident's room, the cord was stretched across the floor posing a possible falls risk, and it was noted in some areas that rolling supply carts were stored in resident's rooms rather than the hallway.
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 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): Oct. 24, 2016 -It was noted that the facility's system for ensuring compliance with monitoring the care plans of residents who have a change in status was ineffective. One of the 3 charts audited stated that a resident exhibited signs and symptoms of a UTI, and documentation stated that nursing was to initiate the facility's UTI protocol however there was no further documentation indicating that this had been done. The resident experienced adverse events ultimately requiring transfer to acute care, and treatment for UTI was commenced while the resident was in acute care. -In the second of the 3 charts audited a dietician had ordered a texture change for a resident, and for nursing to monitor and document the tolerance, however there was no documentation to indicate that the care plan had been updated or that the diet change was being assessed by nursing.
      • 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

    8 infractions

    • 3.2 Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): OUTSTANDING from Sep. 9, 2015 -It was noted that monitoring had not been conducted in the case of resident's changes of status discovered during inspection (antibiotic treatment, UTI management, treatment cream)
      • 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)
    • 17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
      • Observation(s): Please see report - Corrected during inspection.
      • Post the most recent routine inspection in a prominent place.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): OUTSTANDING from Sep. 9, 2015 -It was noted that monitoring had not been conducted in the case of resident's changes of status discovered during inspection (antibiotic treatment, UTI management, and treatment cream) NEW INFRACTIONS from Jan. 15, 2016 -It was noted that a non-"Long Term Care" client had been admitted to the facility. -The most recent monitoring inspection report was not posted. CORRECTED DURING INSPECTION.
      • Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
      • Provide only the type of care that is specified on the license; 46( 2 )(a)
      • Regularly monitor the physical environment and the care and services provided; 61
    • 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): NEW INFRACTION from Jan. 15, 2016 -It was noted that staff were not following the Compliance Plan that the facility put into place in Nov. 2015 in regard to the monitoring of antibiotic treatment, UTI management, and treatment cream.
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): OUTSTANDING from Sep. 9, 2015 -It was noted that monitoring had not been conducted in the case of resident's changes of status discovered during inspection (antibiotic treatment, UTI management, treatment cream)
      • Designate an employee qualified by training and experience to supervise employees who provide care to persons in care, coordinate and monitor the care of persons in care and manage unusual situations or emergencies; 41( 2 )(a)(b)( c)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): NEW INFRACTION from Jan. 15, 2016 -It was noted that food was stored in one medication fridge.
      • 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): NEW INFRACTIONS from Jan. 15, 2016 -It was noted that 2 end of the hall sitting areas had damage to the walls. -It was noted that the stove in one neighbourhood was accessible to residents and able to be turned on. -It was noted that the water cooler in one neighbourhood was leaking. A cloth had been placed on the floor and presented as a tripping hazard. A REQUISITION WAS SUBMITTED TO MAINTENANCE DURING THE INSPECTION. -It was noted that one resident's room contained hazardous, sharp implements and was accessible to other residents.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): OUTSTANDING from Sep. 9, 2015 -It was noted that monitoring had not been conducted in the case of resident's changes of status discovered during inspection (antibiotic treatment, UTI management, treatment cream)
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  10. Monitoring

    8 infractions

    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): 16-Sep-2015 -It was noted that restraint documentation was incomplete.
      • Record the reason for the use of restraint in the person's care plan; 84(b)
      • Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): 16-Sep-2015 -It was noted that a care plan did not include the date of restraint reassessment.
      • 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)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): 16-Sep-2015 -It was noted that monitoring had not been conducted in the case of resident's changes of status discovered during inspection ( skin break down treatment, antibiotic treatment, multiple episodes of emesis, significant weight loss, and infection).
      • Regularly monitor the physical environment and the care and services provided; 61
    • 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): 16-Sep-2015 -It was noted that a dietary consult had not been conducted when there had been significant weight loss as is required by facility policy.
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): 16-Sep-2015 -It was noted that monitoring had not been conducted in the case of resident's changes of status discovered during inspection ( skin break down treatment, antibiotic treatment, multiple episodes of emesis, significant weight loss, and infection).
      • Designate an employee qualified by training and experience to supervise employees who provide care to persons in care, coordinate and monitor the care of persons in care and manage unusual situations or emergencies; 41( 2 )(a)(b)( c)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): 16-Sep-2015 -It was noted that personal information in one dining room was accessible to passersby.
      • 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
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): OUTSTANDING from 15-May-2015 -It was noted that some Resident's rooms have scuffed walls. NEW INFRACTIONS: 16-Sep-2015 -It was noted that dust had accumulated behind some hand rails. -It was noted that the door and walls to a servery were damaged. -It was noted that an outdoor patio floor in one neighbourhood was soiled. -It was noted that a ceiling vent in one dining room was blackened. -It was noted that staff bags in one area were accessible to Residents.
      • 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)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): 16-Sep-2015 -It was noted that monitoring had not been conducted in the case of resident's changes of status discovered during inspection ( skin break down treatment, antibiotic treatment, multiple episodes of emesis, significant weight loss, and infection).
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • Ensure persons in care are not subjected to financial, emotional, physical, sexual abuse or neglect; 52( 1 )(a)
  11. Monitoring

    5 infractions

    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): May 15, 2015 - It was noted that one neighborhood had a sit to stand lift which was soiled.
      • Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): Infraction noted in report.
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): OUTSTANDING from Jan. 7, 2015 - May 15, 2015 - It was noted that a plan had been put into place to maintain confidentiality of the resident's records, however in 4 instances the records were left out where they could be viewed by passersby.
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): OUTSTANDING from Jan. 7, 2015 - May 15, 2015 - It was noted that one neighborhood had fridge temperatures that were recorded inconsistently.
      • Ensure that food is safely prepared, stored, served and handled; 63 (3)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): OUTSTANDING from July 2013 - May 15, 2015 - It was noted that a water dispenser in activity/dining room requires cleaning due to apparent mineral build-up. OUTSTANDING from Jan. 7, 2015 - May 15, 2015 - It was noted that one activity/dining room has water damaged cupboards. - It was noted that one tub room has damaged areas on the wall/ceiling. - It was noted that one elevator has sustained damage to the walls. NEW INFRACTIONS - May 15, 2015 - It was noted that one Resident's room had scuffed walls. - It was noted that three neighborhoods had stained sinks with water damage to the walls behind the taps. - It was noted that one neighborhood had a door open to the patio; it was accessible to Residents and there was a large amount of water on the floor which posed a falls risk. - It was noted that one staff room had an open door; it was accessible to Residents and presented a safety concern. - It was noted that one neighborhood had a stove which was accessible to Residents; this stove did not have a safety switch to prevent the stove from being turned on inadvertently. Licensing received information on May 19, 2015 that the stove had been removed.
      • 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)
  12. Monitoring

    14 infractions

    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): This remains OUTSTANDING from 11-Dec-2014 - A reportable incident of missing/wandering was not reported to Licensing.
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): See comments in the Staffing section.
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): RESOLVED - Charts reviewed contained evidence of TB screening
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): RESOLVED - Sit to stand lift located on the second floor has a crack in the knee pad. - Sit to stand lifts in all areas required cleaning. OUTSTANDING - from July 2013 - Water dispenser in activity/dining room requires cleaning on the outside as well as the tray itself.
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): See Records section of report
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Inadequate maintenance logs provided for electric space heaters.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 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): RESOLVED - Charts reviewed indicated that post falls policy was being followed.
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): RESOLVED - Charts reviewed indicated that 24 hour report documentation was also included in the Resident's progress notes. NEW INFRACTIONS - 07-Jan-2015 -Some staff files inspected noted to be missing or contain only one reference check. -One staff file inspected noted to be missing evidence of TB screening. -Several staff files inspected noted to be missing evidence of immunization screening. -One staff file inspected noted to be missing evidence of a First Aid certificate, and one file contained an expired First Aid certificate.
      • 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 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): NEW INFRACTIONS - 07-Jan-2015 -It was noted that the PIC's binders containing the "My Day", and Care Plan are accessible to passers by. -Two PIC's charts inspected noted to be missing evidence of admission height and weight. -All PIC's charts inspected were missing evidence of consent to call an MD or Ambulance in the event of an accident or illness.
      • Record the height and weight of each person in care on admission; 49 (12)
      • 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)
      • 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
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): NEW INFRACTION - 07-Jan-2015 It was noted that 2 snacks per day are not featured on the weekly menu.
      • 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): RESOLVED - Fridges inspected were found to be clean. NEW INFRACTIONS - 07-Jan-2015 - One fridge log noted to be missing and temperature recording was inconsistent. - All fridges noted to have some undated food items. -Tub rooms and care carts noted to have non-PIC specific cleaners and anti-perspirants.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 (11)
      • Ensure that food is safely prepared, stored, served and handled; 63 (11)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): RESOLVED - Damage to walls of several rooms on the second floor. - Broken/missing electrical outlets. - Closet door in one PIC's room not secure. - Hole in flooring in one PIC's room. - Light covers missing in PIC's bedroom and second floor hallway. - Dried food debris on some dining room tables and chairs. - Dusty window sills in PIC's rooms throughout. - Damaged flooring in one PIC's room. OUTSTANDING - from July 2013 - Sediment from hard water build up to taps and glass walls noted in several small kitchens throughout the facility. - Soiled armchair noted in Kettle Valley dining room. - Flooring along the edges of the baseboards in the hallways and dining rooms throughout the facility had grit and debris present. - Hand rail underneath bulletin board on second floor noted to be dirty as well as debris in groove behind hand rail itself. NEW INFRACTIONS - 07-Jan-2015 -Kitchen drawer contents that PICs have access to noted to require cleaning. -One dining room noted to have cracked paint and water stains on the ceiling. -Some PICs noted to have prescription creams unlocked in their rooms and accessible to other PICs. -One hallway noted to have a damaged bookshelf leaning against the wall for support. -One activity/dining room noted to have a shelved, wicker unit that was tipping to one side. -One acitivity/dining room noted to have a stained and damaged floor. -One activity/dining room noted to have water damaged kitchen cabinets. -One area near an entranceway noted to have a damaged counter. -One tub room noted to have water stains on the ceiling and damage to the floor. -One elevator noted to have damage to the walls. -Damage noted to walls in all of the main areas of the neighborhoods.
      • 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): RESOLVED - Medication administration inspected indicated that medication is being administered as per physician's orders.
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): RESOLVED - Charts reviewed indicated that status changes are being documented.