Skip to content
Loading map…

Summerland Seniors Village

12803 Atkinson Rd Summerland BC V0H 1Z4 · Residential Care - Licensing

39 inspections

  1. Substantiated complaint

    2 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): Allegation – The Licensee is in non-compliance with RCR 85(1)(d), employees implementing policies and procedures, as it pertains to providing feed-assistance to persons in care. An employee(s) was witnessed providing feed-assistance while standing on one or more occasions. Interviews conducted during the investigation determined that feed-assistance while standing had been provided by employee(s) on one or more occasions, and in non-compliance with organizational policies and procedures. Therefore, based on a balance of probability, the allegation of non-compliance with RCR 85(1)(d) is SUBSTANTIATED. The Licensee stated verbally on March 17, 2026 that strategies had already been initiated to come into compliance. There is a risk to the health and safety of persons in care when feed-assistance is not provided in compliance with organizational policies and procedures. The Licensee will submit a Compliance Plan by May 27, 2026 confirming that the non-compliance with feed-assistance has been corrected, and will include the system that will be implemented for ongoing self-monitoring of meal service. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Allegation – The Licensee is in non-compliance with RCR 50(1) as it pertains to regularly monitoring a person in care who was experiencing reddened areas around the eyes to ensure their needs continue to be met. Documentation indicates that the redness around the eyes was first noted nine months before the complaint was brought to Licensing. Multiple records were reviewed including, but not limited to, Nursing Progress Notes, Medication Administration Records, Care Plan, Care Conference documentation, and Physician’s orders. There were orders in place to provide treatment(s) for the reddened areas around the eyes; however, there is no documentation to indicate that the orders for treatments were being implemented. Therefore, based on a balance of probability, the allegation of non-compliance with RCR 50(1) is SUBSTANTIATED. There is risk for worsening health outcomes when monitoring is not being conducted to ensure that a person in care’s needs are being met. The Licensee will submit a Compliance Plan by May 27, 2026 confirming that the non-compliance with a person(s) in care’s care needs being met has been corrected, and will include the system that will be implemented for ongoing self-monitoring. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance. Allegation – The Licensee is in non-compliance with RCR 52(1)(a)(iii) neglect as it pertains to missed bath(s) for one person in care for 11 or 12 days. Interviews conducted during the investigation determined that a bed bath had been provided by two Care Aides during the period referenced in the complaint; however, it had not been documented as given. A bath had been given therefore, the allegation of non-compliance with RCR 52(1)(a)(iii) is unsubstantiated.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  2. Routine Inspection

    2 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): March 17, 2026 The Licensee’s systems for monitoring to ensure that complaints are followed up on and baths are provided in compliance with the legislation is ineffective as stated in the body of this report. If monitoring is not in place to ensure compliance with the legislation there is increased risk to the health, safety or dignity of persons in care. The Licensee will submit a Compliance Plan by April 17, 2026 outlining the systems and monitoring that will be put into place to ensure compliance with the legislation is sustained on an ongoing basis.
      • 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): March 17, 2026 The Licensee received a complaint alleging inadequate provision of care, and it was not investigated in compliance with the organization’s policies and procedures and the legislation. In addition, the person in care was not assessed to determine their status after receiving the allegation. If a complaint is not investigated as per policies and procedures and the legislation there may be a risk to the health, safety or dignity of persons in care. The Licensee will submit a Compliance Plan by April 17, 2026 outlining the systems and monitoring that will be put into place to ensure that all complaints are followed up on in compliance with policies and procedures and the legislation on an ongoing basis The Licensee’s system to ensure that baths are provided in compliance with organizational policies and procedures is ineffective. It is determined that multiple baths were missed and/or not documented for persons in care during January and February. Missed baths may pose a risk to the health or dignity of persons in care. The Licensee will submit a Compliance Plan by April 17, 2026 outlining the systems and monitoring that will be put into place to ensure that baths are provided in compliance with policies and procedures and the legislation on an ongoing basis.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  3. Routine Inspection Follow-up

    0 infractions

  4. Routine Inspection

    1 infraction

    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): December 4, 2024 The Licensee does not have a system in place to ensure that persons in care who may leave a facility without notifying an employee and may not be capable of identifying themselves be fitted with identification that contains the name of the person, community care facility, and emergency contact information, and cannot be easily removed.
      • 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)
  5. Routine Inspection Follow-up

    0 infractions

  6. Routine Inspection Follow-up

    2 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): July 26, 2024 Contravention – During the inspection the Manager reported to Licensing that one or more employees were not following policies and procedures for responding to call bell signals. This was confirmed by Licensing during the inspection.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • 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 26, 2024 Contravention - During the inspection Licensing observed that an employee did not follow a person in care’s care plan directive that states two-person care must be provided for all personal care.
      • 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. Routine Inspection

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): May 14, 2024 Contravention reoccurring from February 23, 2024 Routine Inspection Follow Up – The Licensee submitted three high-risk reportable incidents to Licensing that were not in compliance with the Residential Care Regulation or the Licensee's Compliance Plan as the reports did not include pertinent and detailed information 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): May 14, 2024 Contravention reoccurring from October 27, 2023 Routine Inspection and February 23, 2024 Routine Inspection Follow Up – The Licensee has systems in place to monitor the care and services provided however; monitoring to ensure compliance with three systems, and a Compliance Plan and Health and Safety Plan being followed were ineffective as detailed in this report.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): May 14, 2024 Contravention reoccurring from October 27, 2023 Routine Inspection – A Health and Safety Plan was put into place on April 24, 2024 in response to a reportable incident involving aggression between persons in care. This plan was approved by Licensing. During the inspection this plan was reviewed with the Licensee Representative(s) along with the documented evidence for the monitoring of the plan and the person in care. It was noted the approved plan was not implemented, and the actions taken by the Licensee and employees were not in alignment with the plan approved by Licensing.
      • R3.1N - 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): May 14, 2024 Contravention reoccurring from February 23, 2024 Routine Inspection Follow Up – The Licensee has a system in place to ensure that care plans are updated with a substantial change in the status of a person in care or annually. During the inspection seven care plans were reviewed and the system was noted to be ineffective. One care plan was noted to have an outdated directive for the frequency and type of monitoring for a person in care, and one care plan was to include a Health and Safety Plan approved by Licensing and this was not on the care plan. Contravention – The Licensee has a system in place to ensure that employees implement care plans however, the system was noted to be ineffective. Through the review of documentation it was noted only one employee provided care to a person in care with a care plan stating two employees to provide all care.
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
      • 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 Follow-up

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): February 23, 2024 Contravention – The Licensee submitted a high-risk reportable incident to Licensing that was not in compliance with the Residential Care Regulation; the report did not include pertinent and detailed information 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): February 23, 2024 Contravention – The Licensee submitted a high-risk reportable incident to Licensing that was not in compliance with a Compliance Plan that is currently in place.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • 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 23, 2024 Contravention - During the investigation it was noted that the Licensee had not updated a person in care's care plan to reflect the changes in their care needs.
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  9. Routine Inspection

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): October 27, 2023 Contravention – The Licensee’s system to ensure that the representative, or contact person is immediately notified if a person in care becomes ill or is injured is ineffective. During the inspection of care plans, it was noted that one contained a directive to only notify the representative if the care plan changes. The employee(s) reported that three persons in care’s care plans contained that directive. These directives were changed to reflect the legislation during the inspection. Comment – During the inspection it was noted by an employee(s) and Licensing that a transfer to hospital had not been reported to Licensing. The details of the incident were discussed along with the Schedule D definition of “unexpected illness” to establish clarity moving forward.
      • R4.5A - Immediately notify the parent, representative or contact person if a person in care becomes ill or injured while under the care or supervision of the licensee; 76 ( 1 )
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): October 27, 2023 Contravention – The Licensee has systems in place to monitor the care and services provided however; monitoring to ensure compliance with two systems, and a Health and Safety Plan being followed were ineffective as detailed 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): October 27, 2023 Contravention – The Licensee’s system for ensuring that care plan processes follow facility policies and/or procedures was noted to be ineffective in two cases. Five care plans were reviewed and one was noted to not have a behaviour reassessment(s) conducted as per process, and one person in care’s record indicated that a Braden Scale for predicting pressure ulcer risk had been completed but had not been transferred to the care plan. This information was provided by employee(s) and noted by Licensing during this inspection. Comment – It was noted by Licensing and an employee that one of the five care plans reviewed was missing an assignment of position(s) for a care task. The employee corrected the omission immediately (at the time of inspection). Comment – It was reported by an employee that education will be provided for charting of tasks conducted on night shifts to ensure they are charting as per the facility policies and/or procedures. Comment – Licensing and the Licensee Representative(s) discussed the Licensee’s “Wandering/Missing Resident” policy, with a focus on definitions. The Licensee Representative(s) stated that the policy will be reviewed within the organization to ensure alliance with Residential Care Regulation (RCR), Schedule D, and reporting to Licensing.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): October 27, 2023 Contravention – A Health and Safety Plan was put into place on June 1, 2023 in response to a reportable incident involving an allegation of abuse that was substantiated by the Licensee. This plan was approved by Licensing. Upon review of this plan during this inspection with the Licensee Representative(s), it was determined that the monitoring and documentation was not completed as stated in the Plan, by the employee responsible. As a result, Licensing was unable to assess the outcome of the Plan and whether or not the Licensee was able to address and correct the original concerns involving employee conduct. Comment – Licensing and the Licensee Representative(s) discussed the facility’s system for ensuring compliance with RCR 54(3), evidence of yearly dental exam encouragement, and the system was found to be effective. Upon further discussion regarding the Dental Hygienist’s access to persons in care, the Licensee Representative stated that they will consult with sister sites and report back to Licensing for further discussion.
      • 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)
  10. Routine Inspection

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): April 11 and 12, 2023 The Licensee’s system to ensure compliance with submitting reportable incidents is ineffective. Licensing conducted a review of incident reports submitted in 2023, and multiple reports were noted to be missing information that is required to be included in the report as per the directives on the form.
      • 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): April 11 and 12, 2023 The Licensee has systems in place to monitor the care and services provided however; monitoring to ensure compliance was ineffective as described in the body of this report.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): April 11 and 12, 2023 The Licensee’s system for ensuring that employee files contain all of the legislated requirements was noted to be ineffective. A contracted service provider’s file was reviewed and noted to not contain evidence that the person has complied with the Province’s immunization and tuberculosis control programs.
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
    • R4.6 - Are facility records current and complete?
      • Observation(s): April 11 and 12, 2023 The Licensee does not have a system in place to ensure that Medication Safety Advisory Committee meeting minutes are retained on site, and/or that the Pharmacist’s recommendations are reviewed and followed up on by employees.
      • R4.6A - Keep a copy of each policy and procedure of the medication safety and advisory committee; 85 ( 3 )
    • 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): April 11 and 12, 2023 The Licensee does not have a system in place to ensure that when a care plan is updated for Palliative care, any previous and no longer applicable directives are removed.
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  11. Routine Inspection

    5 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): February 7, 2023 Contravention - The Licensee has systems in place to monitor the care and services provided however, as noted in the body of this report, some systems for monitoring were noted as ineffective. See below contraventions for details.
      • 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): February 7, 2023 Contravention - The Licensee’s system for ensuring the development of care plans is ineffective. During the inspection, three care plans were reviewed and it was noted that one was not developed in accordance with the facility’s process.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): February 7, 2023 Contravention - The Licensee’s system for ensuring that employee files contain all of the legislated requirements was noted to be ineffective. A contracted service provider’s file was reviewed and the documentation was noted to have expired. The Licensee confirmed that the employee had current registration with their licensing body during the inspection. Comment – The Licensee representative reported that employee education for the operation, cleaning, and maintenance of air levels for speciality cushions and/or mattresses was not on site, and that refresher education will be provided and documentation retained.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • R3.1AA - Keep in the case of employees, all records required under section 37 ( 1 )[character and skill requirements] for the entire time that the subject of the records is an employee; 92( 3 )(a)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): February 7, 2023 Contravention - It was noted that the Licensee’s system to ensure a weekly menu is posted in compliance with the legislation is ineffective. During the inspection, it was noted in all dining areas audited that the snacks listed on the menu could not be read due to the darkness of the background colour. Comment - The Licensee reported that they are currently in the process of installing large white boards for the daily menu.
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): February 7, 2023 Contravention - The Licensee does not have a system in place to ensure that OT directives are correct and/or sufficient on care plans. During the inspection, it was noted that one person in care had information on their care plan that did not apply to them, and information was insufficient for employees to monitor air levels and conduct cleaning on speciality cushions and mattresses.
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  12. Routine Inspection

    0 infractions

  13. Routine Inspection

    2 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): June 21, 2022 Contravention – 21(d) The Licensee’s system for ensuring that commodes are maintained in a clean condition is ineffective. During the inspection it was noted that a soiled commode was in the room of a person in care.
      • R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): June 21, 2022 Contravention – 62(4) Although the Licensee posts a weekly menu in the dining room as required, it is apparent the Licensee does not have a system to ensure that the posted menus are accurate and reflect what is actually being served on any given day. Licensing also suggests the daily posted menu be relocated to a more prominent location. Contravention – 35(1)(c) The Licensee’s system for ensuring that hazardous materials are in a safe location is ineffective. During the inspection it was noted that Cavilon cleaning wipes were accessible to persons in care in more than one location.
      • 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)
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
  14. Routine Inspection

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): March 1, 2022 Incident report follow up has identified that the Licensee’s system is ineffective in ensuring that abuse allegations are reported to Licensing immediately. It was noted that two allegations of abuse brought forward to the site leadership against two employees were not reported to Licensing immediately as required by the RCR. Of significant concern is the fact that the two employees who were the subject of the allegations continued to work as the allegations were not reported to Licensing immediately or investigated by the Licensee immediately. During a phone call between Facility Leaders and Licensing on February 4, 2022, it was requested that the facility submit to Licensing a detailed investigation outcome from every reportable incident. Licensing requests that this process continue.
      • 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): March 1, 2022 Community Care And Assisted Living Act Section 9 (1) The director of licensing or a medical health officer may exercise the powers under subsection (2)(a)to determine if a licensee is complying with this Act, the regulations or the terms and conditions of the licence, (c)to determine if there is a risk to the health, safety or dignity of a person in care at a licensed community care facility. The Licensee was noted to be in non-compliance with sections 61, 77(2)(c), and 85(1)(d) during an inspection conducted on December 9, 2021. A Compliance Plan was submitted to Licensing outlining the actions that the Licensee would take to bring the contraventions into compliance. Non-compliance in these sections was noted again during the inspection conducted on March 1, 2022. In addition, non-compliance with section 82 was noted during the March 1, 2022 inspection. The facility remains in Progressive Compliance that was initiated in February of 2020. As a result, Terms and Conditions were attached to the facility's Licence to operate and remain in place to date. Note -– The Compliance Plan from February 25, 2022 states, “Resident and/or POA will be part of all health changes”. The Manager reported that all care plans will be reviewed and revised if required to ensure that every person in care has a named Representative to be utilized as their contact when required.
      • 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): March 1, 2022 Incident report follow-up has identified that the Licensee does not have an effective system in place to ensure that staff follow facility policies and procedures. It was noted that on occasion, employees did not follow the facility’s policies and/or procedures for: submitting a reportable incident, following the nursing job descriptions, following the On-Call Schedule process, and reviewing of care plans. In addition, the Licensee does not have a monitoring system in place to determine if the education that has been provided to employees in response to identified non-compliance has been effective and is being sustained. During the inspection it was noted that Food Service employees were not orientated to the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR). All employees are required to be orientated to the CCALA and RCR.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • 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): March 1, 2022 During incident report follow up and during the inspection, Licensing identified that the Licensee does not have a system in place to ensure employees implement the directives documented in care plans. It was noted that on occasion, employees had not implemented a fall prevention strategy when a person in care sustained a fall, and had not implemented directives on a care plan regarding assessment and transfer to a higher level of care
      • 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
  15. Routine Inspection Follow-up

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Contravention – an effective monitoring system was not in place for this employee. This is evidenced by the documentation reviewed by the Licensing Officer indicating the employee had committed two further known incidents of non-compliance or alleged non-compliance with facility policies and procedures and implementation of care plans leading to emotional abuse of persons in care.
      • 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): Contravention – A review of the documentation submitted to Licensing for the investigation indicates that the Licensee did not follow their policies and procedures for employee performance management. Licensing is aware of two previous substantiated incidents of the employee operating in contravention of facility policies and procedures, and the implementation of care plans leading to emotional abuse of the persons in care. During the investigation of the third allegation, the Licensee brought the employee back to work without receiving approval of a Health and Safety Plan for the employee’s return to work from Licensing. In addition, during Licensing’s investigation it was identified that this employee’s previous two substantiated incidents had not been initially disclosed to Licensing as required.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • 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): Contravention – During the investigation it was identified that there have been multiple incidents of the employee not following care plans leading to emotional abuse of the persons in care.
      • 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
  16. Routine Inspection Follow-up

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): December 9, 2021 The Licensee's Plan for ensuring ongoing compliance with RCR Section 77(2)(c) is ineffective. It was identified by Licensing that one high risk reportable incident had been submitted late and was missing pertinent information. Additionally, two high risk reportable incidents had been submitted in a timely manner; however, they were missing pertinent information.
      • 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): December 9, 2021 The Licensee's system that is in place to monitor Compliance Plans submitted to Licensing is ineffective. There was no evidence to demonstrate that the Compliance Plans were being monitored to ensure that they were effective, and that the facility was operating in compliance with the Residential Care Regulation (RCR) and Community Care and Assisted Living Act. In addition, it was identified by Licensing in November of 2021 and at the time of this inspection, that the monitoring of reportable incidents, care plan reviews, and documentation when persons in care experienced a change in their condition was not 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): December 9, 2021 The Licensee's system for ensuring compliance with policies and procedures as it pertains to staff documenting and/or following up on persons in care's status changes is ineffective.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): December 9, 2021 In review of nursing progress notes Licensing noted that there was inconsistent documented evidence for the monitoring of persons in care when they experienced a change in their condition.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  17. Routine Inspection Follow-up

    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): The system in place to ensure written policies and procedures are in place to guide employees in all matters related to care and supervision is ineffective. Following an incident of service delivery problem directly related to the care and supervision of a person in care, the Licensee failed to update the policy in place to guide employees to prevent reoccurrence of a similar situation.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): 1) The system in place to ensure each person in care is regularly monitored to ensure their needs continue to be met is ineffective. In review of a person in care's progress notes this Licensing Officer noted when a person in care experienced a change in their condition there was inconsistent documentation to indicate the person in care was regularly monitored to ensure their needs continued to be met. 2) The system in place to ensure persons in care obtain health services as required is ineffective. When a person in care experienced a change in their condition the nurse contacted the doctor by the phone and fax. When the doctor's new medication order was not received at the facility the nurses called the doctor's office twice and refaxed once. When the order was not received over a specific number of days, no further actions were taken to ensure the medication order was obtained and administered to the person in care.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • R10.2G - Assist persons in care to obtain health services as required and ensure that a medical or nurse practitioner can be contacted in an emergency;54( 2 )(a),54( 2 )(b)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The system in place to ensure care plans are updated when a person in care experiences a significant change in their condition is ineffective. After review of a person in care's progress notes and care plan this Licensing Officer noted their care plan was not updated when they experienced a significant change in their condition.
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  18. Routine Inspection

    0 infractions

  19. Routine Inspection Follow-up

    1 infraction

    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There are systems in place for the monitoring of employees and persons in care. However, during a review of the daily RN audit this Licensing Officer identified: documentation identifying a person in care's blood pressure was high and it was being monitored. Upon review of the progress notes, person's care plan, and discussions with clinical leaders this Licensing Officer was unable to locate any record of this monitoring occurring.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  20. Routine Inspection Follow-up

    5 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): The compliance plan submitted on May 10 , 2021 outlined nine clinical policies that have been or are in the process of being reviewed and revised. The organization shared a document showing the total number of policies required to be reviewed and revised and the percentage of the policies completed. It appears the organization has reviewed and revised approximately 50% of their policies to date. 1) Licensing has yet to be provided with a plan that identifies how the Licensee will ensure policies and procedures are reviewed and revised at least once a year going forward. 2) Department Managers are monitoring their employee's progress for competition of required policy education on an electronic program called "itacit", and are following up with employees as required. During the inspection, it was noted that the facility's in-house incident reporting policy was not followed. Employees are not consistently completing in-house incident reports at the time of incident occurrence. In addition, the policy for the processing of Doctor's orders continues to not be consistently followed. As evidenced by a second nurse not reviewing and signing off a doctor's order as required; thus a person in care was not reassessed upon completion of their antibiotic.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • 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): The system in place to ensure persons in care's prescribed treatment creams are securely stored is ineffective. This Licensing Officer noted prescription creams in a person in care's bathroom cupboard that were not securely stored.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): See comment in above section R7.1. Note: There is a system in place for the daily auditing of nurse signatures for routinely administered medications and for the documentation of the effectiveness of PRNs administered, Follow up is conducted with the nurses when non-compliance is identified.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There are systems in place for the monitoring of employees and persons in care; however a few items were noted by this Licensing Officer during the inspection that were not identified through the self-auditing process. 1) A person in care was placed on antibiotics for seven days, with the physician in to assess mid week. The documented assessment required further follow-up upon antibiotic completion; however, there was no further assessments documented. 2) A person in care was noted to require dental services. The doctor was notified and they were taken to the dentist by the family. However, this was identified by this Licensing Officer reading the doctor's orders. It was noted there was no documentation of a dental issue, assessment, actions taken or follow up in the person in care's progress notes. 3) A person in care is noted to have a long standing issue of chronic pain. This pain is consistently documented throughout the progress notes as PRN (as needed) medication provided; however, there was no nursing assessment documented or actions taken to proactively address the pain until it was identified by the Interior Health Quality Review Team.
    • 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): It was identified by this Licensing Officer that a person in care's oral care plan was not updated following their visit to the dentist, to reflect the required monitoring going forward.
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  21. Routine Inspection

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): A system is in place for the review of persons in care's progress notes to ensure all incidents are reported as required through both the in-house and Licensing reporting systems. However, during the inspection an in-house incident from early March 2021 was observed to be highlighted in a person in care's progress notes. It was self-identified that an in-house incident report was not completed at the time of the incident; however, there was no follow up action taken at the time of discovering the notation in the progress note.
      • R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(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 compliance plan submitted on April 08, 2021 outlined the schedule for the remaining high priority policies, with April 06, 2021 listed as completion date. The policies continue to been submitted to the Appointed Administrator and Licensing for review to ensure they guide employees and meet legislative requirements. 1) During the inspection this Licensing Officer inquired about the system in place for the ongoing review of all polices and procedures to ensure review and revisions occurs once a year as required. The Interim Educator and the Licensee contact explained the system in place for the continuous review of policies and procedures, and stated they will inform Licensing of the total number of policies reviewed within the last year and how many polices remain outstanding. 2) The Interim Educator and Interim Director of Care continue to provide education and one on one coaching to employees on the facility's polices and procedures. During the inspection it was noted that the facility's in-house incident reporting policy was not followed, nor was a dietary policy for diet textures. In addition, the policy for processing of Doctors orders was not implemented, as the reassessment for a new medication and a medication change was not added to the calendar; therefore the medications were not reassessed as required.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There are systems in place for the monitoring of employees and persons in care; however a couple of items were noted by Licensing during the inspection that were not discovered during the self auditing process. In review of a person in care's nursing notes, it was noted that they had suicidal thoughts. There was no nursing assessment or follow up documentation noted. It appears the doctor was never informed of this health concern. After discussion this issue with the RN, this individual's care plan was updated following this incident.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  22. Routine Inspection Follow-up

    8 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The site continues to work on following up on incident reports within 72 hours of the incident; to ensure facility actions are taken, and documented to mitigate future risk. In review of a persons in care's chart this Licensing Officer identified a reportable incident that occurred 24 hours prior and had not yet been reported. A report was requested to be submitted to Licensing, and has since been received. The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next inspection.
      • 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)
      • R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(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 compliance plan identifies seven policies and procedures to be reviewed and revised in February 2021. Three policies are complete, one is currently being reviewed and two policies still require review and revision. The policy section of the compliance plan is required to be updated. This Licensing Officer reviewed the new process in place for the processing of doctor's orders. It was noted that the new processes is not consistently followed by employees. The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead (Interim Director of Care), and the Interim Educator on the compliance plan and resolving this contravention. Further follow-up will be conducted for this contravention during the next inspection.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Please see comments below in section R4.4.
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): The new spreadsheet for tracking employee performance appraisals indicates there are 32 overdue performance appraisals for clinical staff. The Regional Clinical Lead has a goal of completing all performance appraisals by April 30, 2021. The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next inspection.
      • R4.4D - Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Dietician and Regional Clinical Lead have completed the educational videos for the consistency and textures of therapeutic diets and fluids. All clinical staff are required to watch the videos with the completion of the education tracked in their employee files. Person in care's diets are being added to the new Point Click Care system with education being completed by the Regional Clinical Lead and the Dietician. The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next inspection.
      • R5.1S - Provide adequate food to meet the personal nutritional needs based on Canada's Food Guide, and the person in care's nutrition plan; 66 ( 1 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Auditing of signatures and documented effectiveness of PRN medications administered shows an increase in compliance. However, some non-compliance remains, and the Regional Clinical Lead is currently working with these employees. The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next inspection.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The wound care training modules continue to be completed by nurses. The site has decreased the number of active wounds from 36% to 9%. This Licensing Officer reviewed the wound care book and noted wound care and documentation is not consistently completed as required. This was discussed with the RN and the Regional Clinical Lead. The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next inspection.
      • 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): The Regional Clinical Lead provided additional education to the nurses on sections of the Residential Care Regulations involving care planning. Each nurse has been requested to review the persons in care's care plans that they have completed, to ensure they comply with the legislation. The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next inspection.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  23. Routine Inspection Follow-up

    8 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The newly hired Director of Care is trained and orientated to the system for the review and follow-up of reportable and in-house incidents. As of February 08, 2021 they are responsible for the review and follow up of incident reports to mitigate future risk. The Regional Clinical Lead continues to review and follow-up on all previously submitted incident reports to mitigate future risk. The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • 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)
      • R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(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 Licensee contact provided an updated plan for the review and revision of eight policies and procedures in February 2021, and four in March 2021. Together the Regional Clinical Lead, Interim Educator and the Director of Clinical Care and Education will establish an education plan for the roll out of the updated polices and procedures, and it will be submitted to Licensing upon completion. The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow-up will be conducted for this contravention during the next follow up inspection.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Please see comments below in section R4.4.
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): The new spreadsheet for tracking employee performance appraisals indicates there are 32 overdue performance appraisals for clinical staff. The Regional Clinical Lead has a goal of completing three performance appraisals a week with a completion date of April 30, 2021. The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R4.4D - Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Dietician and Regional Clinical Lead have completed the educational videos for the consistency and textures of therapeutic diets and fluids. All clinical staff are required to watch the videos with the completion of the education tracked in their employee files. The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R5.1S - Provide adequate food to meet the personal nutritional needs based on Canada's Food Guide, and the person in care's nutrition plan; 66 ( 1 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The wound care training modules recommended did not have the ability to print completion certificates; therefore the Clinical Educator resourced new wound care modules that are 50% completed, with the goal of 100% completion by February 26, 2021. The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • 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): The Licensee and the Appointed Administrator continue to work with the Regional Clinical Lead, and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  24. Routine Inspection Follow-up

    8 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Upon follow-up of the in-house incident reporting system, the Appointed Administrator and the interim Director of Care noted incidents that were not followed up to mitigate risk. The Interim Director of Care created a system for the logging, follow up and documentation of actions taken for incidents, and continues to work towards completing follow-up on all previously reported incidents. Additional education has been provided to frontline care staff on the requirements of the Residential Care Regulation and Schedule D regarding the requirement to report to Licensing. The Interim Director of Care and Interim Educator are monitoring persons in care's progress notes and they are working closely with care staff to ensure all incidents requiring in-house incident reports and Licensing reports are filled out and follow-up on as required. In review of persons in care's progress notes and in-house incident reports this Licensing Officer noted an incident of physical aggression/unusual behaviour for an individual whose care plan did not include interventions for physical behaviours. This Licensing Officer explained the incident is reportable to Licensing as it is not previously care planned for. It was identified the care planning program was deleting behavioural interventions currently in place when new behaviour care planning was entered, however this was not noted until discovered by this Licensing Officer. The Licensee and the Appointed Administrator continue to work with the interim Director of Care and the interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • 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)
      • R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(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 current Compliance Plan includes a plan for the review/revision/update of the facility's Oral Health, Admissions, Performance Review, and Contracted Partner/Paid Companion Policies to occur between January and March 2021. A plan was provided for educating employees on these policies. Licensing spoke with the Appointed Administrator, the Interim Director of Care and the newly hired Director of care to inquire about a plan for the development of the remaining policies. The interim Educator and the interim Director of Care are implementing the facility's wound care policy and procedure, and have developed a system for the treatment of wounds, with mentorship provided to the RN. This Licensing Officer reviewed the wound care book containing up-to-date pictures and treatment sheets for current wounds. In review of a person in care's progress notes, this Licensing Officer noted documentation from the previous week for skin excoriation/abrasion, with a treatment applied at that time. The RN and Interim Director of Care stated the process for identified skin issues and treatments is to initiate a treatment sheet, and notify the RN/Director of Care. However, neither of these actions were taken, nor was a follow-up to the issue documented in the persons in care's progress notes since the initial assessment and treatment over one week ago. Employees received education on Interior Health's aggressive and responsive behaviour policy and procedure, with in person education provided by Interior Health's Behaviour Specialist in November 2020. The interim Director of Care and Interim Educator continue to provide 1:1 in the moment education and training to the employees in regards to systems and processes for responsive behaviours. This Licensing Officer reviewed Licensing incident reports, in-house incident reports, and care plans for persons in care who displayed responsive/aggressive behaviours. It was identified that the reported aggressive behaviours were not addressed in their current care plan. In conversations with the Interim Director of Care and the Appointed Administrator it was noted that behaviour interventions were in place; however, from this Licensing Officer's audit it was noted that the care planning program deleted previous interventions when new interventions were entered. It was identified that the new Point Click Care will alleviate this problem. In the review of persons in care's progress notes persons experiencing skin break down or falls did not have up to date Scott Falls or Braden assessments completed (last completed Oct 2020) as required by the facility's policies and procedures. There is no system in place for the immediate processing of Doctors orders. Currently each neighbourhood contains two file boxes located on a wall in the nursing station where faxes sent to and received from doctors are stored. Upon review of the faxes received from doctors it is unclear what actions were taken to process the orders. A faxed stamp is on each fax; however, there is no documentation indicating who it was faxed to, when it was faxed, who faxed it, or if the order was implemented. The Licensee and the Appointed Administrator continue to work with the Interim Director of Care and the Interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Please see comments below in section R4.4.
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): The new spreadsheet for tracking employee performance appraisals indicate there are 44 overdue performance appraisals for clinical staff. The Interim Director of Care has a goal of completing three performance appraisals a week starting January 18, 2021, with a completion date of April 30, 2021. The Licensee and the Appointed Administrator continue to work with the interim Director of Care and the interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R4.4D - Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The dietician provided education to the kitchen staff on textured diets and consistency of fluids for therapeutic diets on November 23, 2020. At that time all thickening agents were removed from the neighbourhood kitchens, and thickened soups and liquids are now delivered from the kitchen. The Interim Director of Care stated the dietician will record a training video on thickening fluids the week of Jan 18, 2021, and care staff will receive either in person training or will watch the video between January 18 and February 28, 2021. The head chef will be responsible to monitor fluid consistency. The Licensee and the Appointed Administrator continue to work with the interim Director of Care and the interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R5.1S - Provide adequate food to meet the personal nutritional needs based on Canada's Food Guide, and the person in care's nutrition plan; 66 ( 1 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): In conducting regular audits of the Medication Administration System the Interim Director of Care identified this remains out of compliance. A training and competency checklist was developed to be utilized by all new hires during orientation, and is expected to be completed by all current Nurses by early January 2021. Continued Education will be provided during regular Nursing meetings by the Interim Director of Care, with an education tracking sheet implemented.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system in place to ensure that persons in care are regularly monitored to ensure their needs continue to be met is ineffective. In the review of persons in care's progress notes documented assessments and changes in person's conditions were noted, without any documented follow-up. A person in care had a significant change in their medication and there was no documented evidence for the monitoring of the individual following the changes. In discussions with the RN and the Interim Director of Care, they stated the process for such a medication change is to initiate a behaviour monitoring sheet and document in the neighbourhood calendar to reassess. However, none of these actions were taken.
      • 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): The system in place to ensure care plans are updated when persons in care experience a substantial change is ineffective. In review of persons in care's progress notes, this Licensing Officer noted a person in care had a significant change in their condition resulting in a change in their mobility transfer. However, upon review of their care plan and their ADL sheet located in their room, neither plans reflected this person in care's current care needs. Persons in care who are noted to have responsive behaviours do not consistently have behavioural care plans in place to address behavioural intervention. The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  25. Routine Inspection Follow-up

    7 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Upon follow-up of the new in-house online incident reporting system, the Appointed Administrator and the interim Director of Care continue to find in-house incident reports that required reporting to Licensing. The interim Director of Care is reporting the incidents to Licensing as they are discovered with Health and Safety Plans to mitigate risk. The interim Director of Care noted that the former Director of Care was not following up on the in-house incidents to ensure risk was mitigated, and therefore she in now following up on all incident reports to mitigate risk. Additional education has been provided to frontline care staff on the requirements of the Residential Care Regulation and Schedule D regarding the requirement to report to Licensing. The interim Director of Care and interim Educator are monitoring persons in care's progress notes and they are working closely with care staff to ensure all incidents requiring in-house incident reports and Licensing reports are filled out and follow-up on as required. The Licensee and the Appointed Administrator continue to work with the interim Director of Care and the interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • 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)
    • 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 current Compliance Plan submitted includes a plan for the review/revision/update of the facility's Oral Health, Admissions, Performance Review, and Contracted Partner/Paid Companion Policies to occur between January and March 2021. A plan was provided for the education to employees on these policies. However, Licensing has yet to receive an overall plan or schedule for the review/revision/update of the facility's remaining policies. The Licensee has adopted some of Interior Health's policies and procedures. The Appointed Administrator provided three weeks of education to the employees on these adopted policies. The interim Educator and the interim Director of Care are implementing the facility's wound care policy and procedure, and they are developing a system for the treatment of wounds. These individuals are mentoring the RN who attended in person wound care education at Interior Health. This Licensing Officer reviewed the wound care treatment book for persons with active wounds and noted wound care remains in non-compliance. Employees received education on Interior Health's aggressive and responsive behaviour policy and procedure, with in person education provided by Interior Health's Behaviour Specialist. This Licensing Officer reviewed persons in care's charts with responsive behaviours, and noted non-compliance in regards to following the responsive behaviour policy and procedure. The Licensee and the Appointed Administrator continue to work with the interim Director of Care and the interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): Each department has developed a schedule to conduct all overdue performance appraisals, with the final completion date of March 31, 2021. Upon the follow-up of clinical employee's performance appraisals, the Appointed Administrator noted the former Director of Care did not complete the performance appraisals as per the developed schedule. The Licensee and the Appointed Administrator continue to work with the interim Director of Care and the interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R4.4D - Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): 1) There is no system in place to ensure that menu substitutions from the same food group with similar nutritional value are provided. The interim Educator identified the kitchen stopped serving scrambled eggs and pureed protein bowls at breakfast. An investigation discovered this was stopped as frontline staff were not serving the products to the persons in care. A Health and Safety Plan was provided when the incident was reported to Licensing as a Service Delivery problem. 2) The dietician provided education to the kitchen staff on textured diets and consistency of fluids for therapeutic diets. All thickening agents have been removed from the neighbourhood kitchens, and all thickened soups and liquids are delivered from the kitchen. The Appointed Administrator stated the dietician will provide education on textured therapeutic diets to the frontline care staff in the near future. Clinical staff have received training on mealtime observation tool and swallowing screen in December 2020; with specific instructions to notify dietary staff if foods are of an inappropriate texture, and to not provide these foods to persons in care. The Licensee and the Appointed Administrator continue to work with the interim Director of Care and the interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R5.1S - Provide adequate food to meet the personal nutritional needs based on Canada's Food Guide, and the person in care's nutrition plan; 66 ( 1 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): In conducting regular audits of the Medication Administration System the interim Director of Care has identified this remains out of compliance. A training and competency checklist was developed to be utilized by all new hires during orientation. The new competency checklist is expected to be completed by all current Nurses by early January 2021. Continued Education to be provided during regular Nursing meetings by the interim Director of Care, with an education tracking sheet implemented.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
      • 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): The system in place to ensure care plans are updated when persons in care experience a substantial change is ineffective. Persons in care who are noted to have responsive behaviours do not consistently have behavioural care plans in place to address behavioural intervention. The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
  26. Routine Inspection Follow-up

    8 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The system in place for the documented reassessments of restraints is ineffective. The Licensee is not ensuring the employees are consistently reassessing and documenting the outcome of the reassessments for the continued use of restraints. This Licensing Officer reviewed two person's in care's charts, and noted one person's restraint was not reassessed and documented as required per their restraint care plan. The Licensee and the Appointed Administrator continue to work with the interim Director of Care and the interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system in place to ensure all in-house incident reports are investigated and risk is mitigated is ineffective. Upon follow-up of the new in-house online incident reporting system the Appointed Administrator noted that the former Director of Care was not following up on the in-house incidents to ensure risk was mitigated. Additional education has been provided to frontline care staff on the requirements of the Residential Care Regulation and schedule D regarding the requirement to report to Licensing aggressive/unusual behaviour and aggression between persons in care. The interim Director of Care and interim Educator are monitoring persons in care's progress notes and they are working closely with care staff to ensure all behaviours requiring in-house incident reports and Licensing reports are filled out as required. The Licensee and the Appointed Administrator continue to work with the interim Director of Care and the interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • 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)
      • R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(a)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): An Interim Director of Care arrived at the facility on Dec 12, 2020 to provide support and mentorship to the current nursing staff. This individual will work with an interim educator who also arrived at the site this week from another facility within the organization. Together with the oversite of the Appointed Administrator these individuals will develop a comprehensive compliance plan to resolve outstanding contraventions and develop systems for the regular monitoring of the physical environment, the employees, and the care and services provided to the persons in care. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The Director of Operations is resubmitting a support plan to Licensing that outlines the employees who are responsible for providing support to the site including each individual's specific duties. The submitted plan will also included a comprehensive plan for the development and rollout of policies and procedures, along with a plan for educating the employees on the new policies and procedures. The Licensee has adopted some Interior Health Authority policies and procedures. The Appointed Administrator provided three weeks of education to the employees on the Interior Health policies that have been adopted. The interim Educator and interim Director of Care are implementing the facility's wound care policy and procedure and they are developing a system for the treatment of wounds. These individuals are mentoring the RN who recently attended in person wound care education at Interior Health. Employees recently received education on Interior Health's aggressive and responsive behaviour policy and procedure, and attended in person education provided by Interior Health's behaviour specialist. The Licensee and the Appointed Administrator continue to work with the interim Director of Care and the interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): Each department has developed a schedule to conduct all overdue performance appraisals, with the final completion date of March 31, 2021. Upon the follow-up of clinical employee's performance appraisals the Appointed Administrator noted the former Director of Care did not complete the performance appraisals as per the developed schedule. The Licensee and the Appointed Administrator continue to work with the interim Director of Care and the interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R4.4D - Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The dietician provided education to the kitchen staff on textured diets and consistency of fluids for therapeutic diets. All thickening agents have been removed from the neighbourhood kitchens, and all thickened soups and liquids are delivered from the kitchen. The Appointed Administrator stated the dietician will provide education on textured therapeutic diets to the frontline care staff in the near future. The Licensee and the Appointed Administrator continue to work with the interim Director of Care and the interim Educator on the compliance plan and resolving this contravention. Further follow up will be conducted for this contravention during the next follow up inspection.
      • R5.1S - Provide adequate food to meet the personal nutritional needs based on Canada's Food Guide, and the person in care's nutrition plan; 66 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
      • 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): The system in place to ensure care plans are updated when persons in care experience a substantial change is ineffective. Persons in care who are noted to have responsive behaviours do not consistently have behavioural care plans in place to address behavioural intervention. All persons in care's dietary care plans have been updated by the dietician and include their type of diet and therapeutic diets. The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  27. Routine Inspection

    11 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The system in place for the documented reassessments of restraints is ineffective. The Licensee is not ensuring the employees are consistently reassessing and documenting the outcome of the reassessments for the continued use of restraints.
      • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system in place to ensure all reportable incidents are reported to Licensing immediately following a reportable incident is ineffective. In the review of in-house incident reports, an incident was noted where a person in care displayed aggressive and unusual behaviour towards another person in care that was not previously assessed and care planned for; however, this incident was not reported to Licensing as a reportable incident. In review of a person in care's chart, a fax to the doctor was noted stating the person in care had two incidents of aggressive unusual behaviour towards other persons in care, 10 days apart. However, only one incident was reported in an in-house incident report and a reportable Incident Report was not received by Licensing.
      • 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)
      • R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(a)
    • RB1.1 - Are all policies and procedures available to persons in care?
      • Observation(s): Please see comment in report under Section R2.1
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The system in place to ensure there is regular monitoring of the care and services provided to persons in care is ineffective. This is evident by the contraventions listed 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): The licensee is in the process of adopting new policies and procedures, and education is currently being provided to employees for the next three weeks. The review of persons in care's charts revealed that there is no policy or procedure in place to guide employees in wound care practices. Wound care sheets are inconsistently completed and were noted to be missing pertinent information to guide employees in completing wound care to meet the needs of the persons in care. A plan is required to be submitted to Licensing to identify the system going forward, for the yearly review and revision of policies and procedures as required. The Licensee is not ensuring policy implementation by employee for aggressive behaviours. In review of persons in care's charts, reassessments are not being conducted and documented for individuals with aggressive behaviours as per the policy.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The Licensee has implemented an excel spread sheet for the tracking of employee files to ensure documents that expire are renewed prior to their expiry date. The Licensee has put a system into place to ensure employees will not be scheduled for orientation until all required documents have been obtained. An employee hired prior to the new system being put into place, is currently working in a server position without a food safe certificate.
      • R3.1Q - Ensure employees responsible for the preparation and delivery of food have the necessary experience, competence and training to ensure that food is safely prepared and handled, and meets the nutrition needs of persons in care; 44 ( 1 )(a)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system in place to ensure that persons in care's monthly weights are taken and recorded is ineffective. In discussions with the Dietician and review of persons in care's monthly recorded weights, it was noted that person's weights are inconsistently documented.
      • 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)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): Each department has developed a schedule to conduct all overdue performance appraisals, with the final completion date of March 31, 2021.
      • R4.4D - Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The system in place to ensure that persons in care are provided with the diet documented in their nutritional assessment is ineffective. During the inspection this Licensing Officer observed a person in care coughing excessively when they tried to eat the soup that was provided to them. The person in care's nutritional assessment stated nectar thick fluids. When this Licensing Officer inquired on the consistency of the soup provided to the person the employee showed the soup and stated a nectar thick soup did not come from the kitchen. The employee stated they tried to thicken it with a product they had; however, it was not thickening to the proper consistency for the person in care.
      • R5.1S - Provide adequate food to meet the personal nutritional needs based on Canada's Food Guide, and the person in care's nutrition plan; 66 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There is no system in place to ensure that persons in care are monitored regularly to ensure their needs continue to be met. In review of persons in care's charts this Licensing Officer noted suicide risk assessments, and depression rating scales with moderate to high scores. The assessment forms stated increased frequent monitoring is required for the persons as an intervention. However, their care plans did not reflect the outcome of these assessments, nor did it direct employees to increase the frequency for the monitoring of these persons.
      • 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): The system in place to ensure care plans are updated when persons in care experience a substantial change is ineffective. Persons in care's care plans do not consistently identify the changes in their condition. Persons in care who are noted to have responsive behaviours do not consistently have behavioural care plans in place to address behavioural intervention. Persons in care's nutritional care plans do not specify the nutrition to be provided, including the therapeutic diets that are listed in the nutritional assessments.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3E - Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  28. Routine Inspection Follow-up

    4 infractions

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving the contraventions in regard to employee files. Further follow up will be reviewed for this contravention during the next follow up inspection. A new system has been put into place for the orientation of new employees. The new system includes training the employees who provide the orientation, and a two day in-class orientation to facility policies, emergency preparedness and Residential Care Regulation and the Community Care and Assisted Living Act, in addition to the shadowing shifts on the floor. The Director of Care reviews the orientation check list once orientation is completed, and follows up with the employee to assess if further orientation is required.
    • 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 Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
  29. Routine Inspection Follow-up

    11 infractions

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • 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 Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R10.1 - Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • 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 Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
  30. Routine Inspection Follow-up

    12 infractions

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R6.1 - Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
      • R6.1A - Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • 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 Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R10.1 - Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • 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 Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
  31. Routine Inspection Follow-up

    14 infractions

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): It was identified through internal audits that the system in place for in-house incident reporting and reporting incidents to Licensing is ineffective. The Director of Care and the Appointed Administrator are currently investigating where and how the system in place broke down and will provide a Health and Safety plan to Licensing to mitigate future risk.
    • R6.1 - Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R9.2 - Does the supervising pharmacist consult with employees respecting medication interactions and other problems related to medication?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • 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 Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R10.1 - Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
    • 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 Licensee and the Appointed Administrator continue to work on their compliance plan and resolving this contravention. Further follow up will be reviewed for this contravention during the next follow up inspection.
  32. Routine Inspection

    5 infractions

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): There is no system in place to monitor the orientation process for Health Care Aides to ensure it is effective and they are adequately trained to provide care to persons in care. The orientation process for Health Care Aides (HCA) was reviewed. It was discussed that the current HCAs who are responsible to orientate new employees have not been provided with adequate training and expectations of how to orientate new employees. Newly hired HCAs have reported to IHA employees at the site that they did not receive adequate training and support during orientation. There is no system in place for the review of HCAs orientation check lists, or to connect with newly orientated HCAs to inquire if they require additional training or support prior to working alone.
      • 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)
    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): There is no system in place for the monitoring of the electronic medication system to ensure that employees are administering medications to persons in care as ordered by physicians, and to ensure the medications administered to persons in care are documented as required. Licensing Officer (LO) reviewed a three week audit from July 23, 2020 to August 05, 2020 of the electronic medication system, and noted 80 missing signatures for the administration of routine medications. The nurses are unable to identify if the medications were given as ordered. The pharmacist was not notified of the missed signatures and the possibly missed medication administration, as required. Licensing requested and received a Heath and Safety Plan to mitigate immediate risk. The plan included notification to the pharmacist of all medication errors.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): 1) A Compliance Plan was submitted and accepted by Licensing on June 25, 2020, for the process of reviewing and updating the facility's policies and procedures. However, the individual who submitted the compliance plan and was responsible for reviewing and updating policies and procedures is no longer with the organization. The IHA appointed Administrator notified Licensing when the individual left their position and stated the review and updating of policies is currently on hold until an individual is hired into this position. Following the receipt of this inspection report the Licensee is required to submit a plan to Licensing outlining how this contravention will be addressed and resolved as it remains outstanding from the February 2020 report. 2) The system in place for ensuring the facility's polices and procedures for restraints is implemented and followed by employees is ineffective. LO reviewed the documentation for the monitoring of persons in care while in restraints. The documentation showed the initiation of the restraint for two persons in care at 0930 and 1112 that day. However, at 1445 there had been no further documentation to indicate that the persons had been monitored every 2 hours as per the restraint policy and procedure. This was originally noted during the February 2020 inspection. 3) There is no system in place to ensure that all employees are orientated to the Community Care and Assisted Living Act and the Residential Care Regulation. This remains outstanding from the February 2020 inspection.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): 1) A system has been established for the tracking and monitoring of employee files to ensure files contain the required documents as per the Residential Care Regulation. The employees required to have a current food safe certificate have been identified. The employees without a current food safe certificate are currently enrolled in the food safe program. These employees are monitored by the Kitchen Manager for the safe preparation and serving of food. 2) There is no system in place to ensure that employees comply with the policies and procedures of the medication safety and advisory committee. In discussions with an IHA employee it was identified that the nurses administering medications do not consistently sign for all routine medications in the electronic medication record (E-MAR). The E-MAR flashes when a signature is missed for a routine medication. The nurses are ignoring the flash warning and not returning to the date and time to ensure the medication was administered and signed for. Non-compliance was identified by the IHA employee and they started a problem solving process that included the following actions: 1) replacing computers and scanners, 2) removing all non medicated prescriptions from the E-MAR, 3) providing additional education to nurses on the E-MAR system. However, these errors continued to occur. Licensing was not notified of this non-compliance prior to the inspection, nor was a Health and Safety Plan created and put into place to mitigate risk. Licensing requested, received and approved a Health and Safety Plan on August 06, 2020 for this issue.
      • R3.1Q - Ensure employees responsible for the preparation and delivery of food have the necessary experience, competence and training to ensure that food is safely prepared and handled, and meets the nutrition needs of persons in care; 44 ( 1 )(a)
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): A system has been established for the tracking and monitoring of employee files to ensure files contain the required documents as per the Residential Care Regulation. The licensee has sent letters to employees requesting the submission of missing documents by a specified date. 1) Through the licensee's audit of employee files and the creation of the tracking system it was identified that one Health Care Aide does not have a current Criminal Record Check (CRC) in their file. Licensing was not informed of this issue at the time it was discovered, nor was a Health and Safety Plan implemented. During the inspection when Licensing was notified of this issue Licensing requested, received and approved a Health and Safety Plan on August 5th, 2020 stating this employee will not work alone and will partner with an employee who holds a current CRC at all times until their CRC is received. The LPN and RN will monitor this employee to ensure that the H&SP is followed at all times. 2) Employees are experiencing difficulty in obtaining TB screening due to COVID-19 as the testing is not occurring consistently in all Health Centers at this time. These employees continue to work towards obtaining TB screens and immunization screening. 3) Each department has completed a plan for the completion of employee's performance reviews. These plans are requested to be included in the compliance plan submitted to Licensing following the receipt of this report. 4) A system has been put into place for obtaining character references for newly hired employees. Licensing has approved the plan going forward for all newly hired employees to obtain a minimum of two character references. The above contraventions remain outstanding from the February 2020 inspection. Employees that are required to have current first aid and CPR have recently completed the required training and their certificates are in their files.
      • R4.4A - Keep employee criminal record check results; 86(a)
      • R4.4C - Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
      • R4.4D - Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
  33. Routine Inspection Follow-up

    4 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): A system has been established to review all current persons in care's charts and contact physicians, health units and pharmacies to obtain immunization history. Doctors are currently being contacted for immunization orders. The RN will conduct an immunization clinic to immunize all persons who require and choose to update their immunization status. A system has been established to record persons in care's immunization status in one location in their chart. A system has been established to ensure that all persons who are newly admitted to the facility will have an immunization screen completed and any immunizations required will be administered and documented. This contravention remains unresolved as this remains in progress.
      • 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): 1) A system has been put into place for responding to all concerns and complainants in a timely manner, and for maintaining a record of the responses. 2) A system has been established to provide ongoing education to employees on facility policies and procedures, including the monitoring of employees to ensure the facility's policies are implemented. 3) Licensee has implemented a process for contracted employees to receive a five day orientation upon their hire. 4) Compliance plans that have been submitted to Licensing have either been resolved or they are being followed. 5) The facility's influenza policy and procedure and the Public Health Orders related to COVID-19 have been implemented and are being followed and monitored. 6) Employees have received education, resources and ongoing training for aggressive/responsive behaviours. Employees continue to be monitored for proper implementation of the policy and procedure for aggressive/responsive behaviours. 7) Employees have received education, resources and ongoing training for in-house incident reporting and incident reporting to Licensing. 8) The facility's investigation policy is being followed and the IHA appointed Administrator oversees investigations. The Licensee is working with the IHA appointed Administrator and IHA employees to update and create new policies and procedures to reflect the systems and processes that have been implemented. This contravention remains unresolved at this time as this work is in progress.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): The facility Manager is in the process of creating a system for the review of all employee files. A spreadsheet will be created that includes the Residential Care Regulations that pertain to employee files to ensure certificates that expire are tracked and renewed prior to their expiration. This contravention remains unresolved as this remains in progress.
      • R4.4A - Keep employee criminal record check results; 86(a)
      • R4.4B - Keep employee character references; 86(b)
      • R4.4C - Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
      • R4.4D - Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): 1) There is no system in place to ensure the regular monitoring of persons in care who are in the common areas of the locked dementia units. There is no system in place to ensure that employees communicate with each other to ensure regular monitoring occurs of common areas while employees are on breaks or occupied with a person in care behind closed doors. 2) A system has been put into place for the daily monitoring of persons in care's progress notes and each unit's 24 hour report to identify any changes in persons in care's conditions. This process also provides the opportunity to identify incidents or unusual events that have occurred. The RN then follows up with the nursing teams and documents accordingly.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  34. Routine Inspection Follow-up

    12 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): This section remains out of compliance.
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): This section remains out of compliance.
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): This section remains out of compliance.
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): This section remains out of compliance.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): This section remains out of compliance.
    • 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): This section remains out of compliance.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): This section remains out of compliance.
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): This section remains out of compliance.
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Upon entering the facility signs are present notifying visitors of Influenza season and Covid-19. There is hand sanitizer and masks readily available on a table located just inside the front doors. There are other sections in this section that remain unresolved.
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): A system has been established and an audit sheet is in place to monitor the physical environment, and the furniture for cleanliness and to ensure it is in good condition. A portion of this section remains out of compliance.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): This section remains out of compliance.
    • 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): This section remains out of compliance.
  35. Routine Inspection

    17 infractions

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): See comment above in R3.1
    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): There is no system in place to ensure that Medication Administration Records (MARs) are completed as required. This contravention is unresolved from December 18, 2019 inspection. Upon inspection of all four neighbourhood's MARs it was noted that routine medications, PRNs and treatment creams are not consistently administered, or signed for as ordered.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The system in place for the management of restraints is ineffective. This contravention is unresolved from December 18, 2019 inspection. Restraint care plans do not consistently meet all of the legislative requirements. A falls care plan was noted to have a lap belt listed; however it did not contain the reason for the restraint, any alternatives that had been trialled, the duration of the restraint, or the monitoring required. In addition, LO observed documentation is not consistently completed for the monitoring and reassessments of persons in care who have restraints in place.
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
      • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): 1) There is no system in place to ensure that reportable incidents are reported immediately to Licensing and the funding program as required. This contravention is unresolved from the February 27, 2019 inspection. Upon review of persons in care's nursing notes and in-house incident reports, LO identified incidents that were not reported to Licensing and to the funding program. LO required a H&SP to be submitted to Licensing explaining how the Licensee will ensure all employees are educated on Schedule D definitions of reportable incidents, and that reportable incidents are submitted immediately following the incident. 2) There is no system in place to ensure that all non-reportable minor incidents that occur involving persons in care are recorded and retained. In discussions with the Maintenance Manager they stated that a minor accident occurred causing injury to a person in care. LO confirmed that the family was not notified and the incident was not recorded on an in-house incident report. .
      • 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)
      • R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(a)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The system to obtain immunization screening for all persons in care is ineffective. This contravention is unresolved from the December 18, 2019 inspection. Upon review of persons in care's charts, the LO identified that immunization screening is not consistently documented for tetanus and diphtheria, and pneumovax vaccines. Also, In the documentation indicated the immunization status is unknown with no documented follow up with family doctors or person in care's representatives to determine if the persons in care were offered the vaccine(s).
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): There is no system in place to ensure that the furniture used by persons in care is maintained and in a good state of repair. A chair was noted in a downstairs unit that was ripped with the wooden frame exposed, and the seat of the chair was thin and threadbare.
      • R7.2N - Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): See note in above section R10.3
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): UNRESOLVED from December 2019 There is no system in place to ensure there is regular monitoring of the physical environment and the care and services provided to persons in care. This is evident by the contraventions listed 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): 1) There is no system in place to ensure that all complaints, concerns and disputes are responded to promptly. LO observed documented concerns that had been brought forward in mid January and in discussions with the Director of Care (DOC) it was identified that they had not been addressed or responded to. 2)The system in place to ensure that employees implement facility policies is ineffective. Employees not implementing a variety of the facility's policies is UNRESOLVED from July 18, 2019 Inspection Contract employees are considered to be employees of the facility as per the definition of employee in the Community Care and Assisted Living Act; however the licensee is not providing contracted employees with the same 5 day orientation as the employees they hire. Currently contracted employees receive a 1 shift orientation. 3) There is no system in place to ensure that employees and all managers are orientated to the Residential Care Regulation and the Community Care and Assisted Living Act. The current orientation checklist states orientation to the Health Authority, and community partners but not specifically the legislation. In discussions with various department managers it was noted that full orientation was not completed in a timely manner from their start date and as per the facility's policy. This contravention remains unresolved from the December 18, 2019 inspection. 4) Employees are not following the site's compliance plan that was submitted to Licensing in regards to obtaining consent from family for restraints. The facility plan stated verbal consent would be obtained and documented if they were unable to obtain written consent. The plan stated the conversation between representative and employee would be documented as part of verbal consent. During this inspection a written consent was observed to only include the physician's consent and noted verbal consent was obtained by representative; however per facility plan policy the conversation with the representative was not documented by an employee. 5) Employees are not following the facility's influenza policy. In discussion with the licensee, they stated that the facility's policy directs that during influenza season signage is posted at the front door with masks; however this is not currently in place. The policy also states that employees who have not received the influenza vaccine will wear a mask while in care areas; however there is no system in place to monitor which employees have or have not received the vaccine to ensure that they are wearing masks. 6) Employees are not following the facility's policy for aggressive or responsive behaviours. Upon review of persons in care's charts it was noted that the facility's policy is not being followed for every person who is identified as having responsive behaviours. For example person's charts were inconsistently identified in a purple binder, and other documentation did not identify the behaviours or interventions that staff should be using to support persons in care. 7) Employees are not following the facility's in-house incident policy. Employees have started to record in-house incidents; however the last page of the incident report is not completed with the follow up into the incident and the facility's actions to mitigate future risk. 8) Employees are not following the facility's investigation policy. During this inspection the LO discovered multiple in-house incident reports and notations in nursing notes indicating: Incidents of neglect of persons in care, LPNs noted to be sleeping during shift, 24 hour shift report not being completed and missed medications. All of these involving persons in care employees not meeting employment requirements and not meeting persons in care's needs have not been in investigated. Upon review with Director of Care (DOC) it was confirmed that these incidents had not been investigated thoroughly, and employees implicated in these incidents have continued to work without the concerns being addressed. LO requested an immediate Health and Safety Plan (H&SP) outlining how the site would immediately investigate these concerns and ensure the health and safety of all persons in care during the investigation.
      • R2.1L - Respond to all complaints, concerns, disputes promptly. 60(c)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): There is no system in place to ensure that an employee is available to supervise employees who provide care to persons in care, coordinate and monitor the care of persons in care, and manage unusual situations. Currently the Manager, the DOC, Assistant Director of Care (ADOC) and an RN all work Mon-Fri 0800-1600. A sign is posted outside of the nursing stations stating "only call on-call manager for: natural disasters, elevator issues, death of a resident, or any colour codes called". Therefore there is no supervision on evenings, nights or weekends. The licensee stated effective immediately the ADOC and RN will work 12 hour shifts and alternate weekends. The sign regarding on-call manager will be taken down immediately and replaced with a new sign indicating the on-call manager may be called at any time for questions and support. LO required the plan that was provided verbally to be submitted to Licensing immediately in a written H&SP to indicate how all employees will be notified of this change.
      • R3.1N - 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)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): There is no system in place to ensure that employee files are maintained and monitored as per the legislation. Upon review of employee files, it was noted that the required documentation was not in place.
      • R4.4A - Keep employee criminal record check results; 86(a)
      • R4.4B - Keep employee character references; 86(b)
      • R4.4C - Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
      • R4.4D - Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): There is no system in place to ensure that snacks from two different food groups are listed on the menu as per legislation below: 62(2)A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with snack containing at least 2 food groups as described in Canada's Food Guide.
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): 1) There is no system in place to ensure that personal hygiene items are labelled and used only for that individual to maintain health and hygiene. This remains unresolved from the December 18, 2019 inspection. Upon the physical inspection of tub rooms an unlabelled, well-used, single use, disposable razor was observed in a drawer, along with an unlabelled tooth brush, and unlabelled combs which appeared to have been used for multiple persons in care. 2) There is no system in place for the monitoring of personal fridges located in persons in care's rooms to ensure that the food is safely stored. Upon the physical inspection, the LO noted a person in care's fridge to not have a thermometer in it, there was no documented evidence that the fridge was being monitored for the temperature of the food being stored or for how long the undated food was in it.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): There is no system in place to regularly monitor and inspect persons in care's rooms. This contravention is unresolved from the December 18, 2019 inspection. Upon the physical inspection, the LO noted a sharp metal nail file and a disposable razor unlocked in a person in care's bathroom in the locked dementia unit. LO discussed the findings with the licensee to inquire the expectations for these items. They identified that the expectation is that items are labelled and located in the tub room.
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): See comment above in section R4.2
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): 1) The system in place to ensure the regular monitoring of persons in care to ensure that their needs continue to be met is ineffective. The facility has a system in place for the monitoring of persons in care who reside in the secured dementia units. Employees are required to physically monitor and document the monitoring of persons in the common areas every 15 minutes. However; the documentation is not consistently completed, nor are employees consistently in the common areas every 15 minutes to conduct the monitoring. LO was on the units and observed 25 minutes before an employee arrived in the common area, leaving multiple persons in care unsupervised. In reviewing persons in care's nursing notes it was noted on multiple occasions where persons had changes in their condition and there was no follow-up assessments or notes documented to indicate if it was resolved or if the condition was continuing to date. 2) There is no system in place to monitor persons in care to ensure that they are not subjected to harmful actions. Upon chart audits, it was noted that multiple persons in care had noted bruising to upper arms over a four month period. This had not been reported by employees to management therefore not investigated until management was made aware. A H&SP was immediately requested, submitted, and accepted by Licensing and the facility began it's investigation on Feb 11, 2020 into the incidents. Upon further review of nursing notes, the LO identified a documented incident where a person in care was noted by an employee at 1500 to not have received care that day. Once brought to the LPN's attention a care aide provided care to the person. However; this was not reported by the LPN to management and no investigation had been conducted. LO requested an investigation into the incident be conducted by the licensee and a H&SP to be submitted to Licensing immediately that outlined how risk to persons in care would be mitigated.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • R10.2D - Ensure persons in care are not subjected to financial, emotional, physical, sexual abuse or neglect; 52( 1 )(a)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): 1) The system in place to ensure that behaviour care plans are in place to address behavioural intervention is ineffective. This contravention remains unresolved from the December 24, 2019 inspection. Upon review of persons in care's behavioural care plans, it was noted that individuals displaying responsive behaviours do not consistently have plans in place to address the behaviour and guide employees in interventions. A H&SP was submitted to Licensing stating the two persons in care involved in a reportable incident had behaviour care plans in place and updated. Upon inspection only one of these persons had their care plan updated. 2) There is no system in place to ensure that persons in care's care plans are updated when they experience a substantial change in their condition. This contravention remains unresolved from the November 14, 2019 inspection. A person in care was involved in a reportable incident and when they returned from the hospital the care plan was not updated to reflect these changes. This was brought to the DOC's attention in mid January, and upon Licensing's inspection the care plan has not been updated to reflect the changes. 3) There is no system in place to ensure that employees seek immediate advice from a health care provider if a person in care experiences unintentional and significant change in weight. LO observed in a person in care's electronic chart a weight loss of 4.7 kg in one month. There was no documentation to indicate that this was acknowledged or assessed by a health care professional. The dietician reviewed the person in care's chart for the care conference the following month of the two recorded weights, however; there was no documentation to indicate that the weight loss was noted or assessed.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
      • R10.3R - Seek immediate advice from a health care provider if a person in care has experienced unintentional and significant change in weight; 83( 4 )(b)
  36. Routine Inspection Follow-up

    7 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): A restraint care plan does not contain consent from the person in care or their representative.
      • R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Medication and treatment administration records are missing some signatures to indicate they have been administered.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): Restraint records are incomplete.
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The systems to record and track responsive behaviours are not consistent with the facility policy, "Aggressive Behaviour (Prevention & Management)/Purple Dot Alert" policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): - The effectiveness of PRN’s are not consistently recorded.
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): - Immunization status for some persons in care are recorded as unknown. -Weights have not been consistently recorded every month.
      • R4.1C - Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78( 1 )(a) Director of Licensing Standards of Practice: Immunization records
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Prescription creams, cleaners and other hazardous products are accessible in washrooms.
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
  37. Routine Inspection

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): An incident from November 1, 2018 was identified as a reportable incident that has not been submitted to licensing. In addition, reporting delays have been observed on three occasions in November and December 2018.
      • 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 Community Care Facility Licence, last inspection report and the Residents Bill of Rights are obstructed today by a tall plant. When this brought to the attention of management, it was resolved during inspection.
      • R1.1N - Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
      • R1.1O - 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)
      • R1.1Y - Display the rights of adult persons in care in a prominent place and in a form acceptable to the minister; Act 7( 1 )(c.1)(i)(ii)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): It was reported and confirmed that an employee responsible for the program of activities has been taking persons in care off site without a current first aid/CPR certificate.
      • 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)
  38. Monitoring

    5 infractions

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): The Licensee has made progress to supplement staffing levels and recruitment and retention strategies in order to bring the facility up to full staffing levels. Upon review of care plans related to bathing routines at the time of this visit, some baths are still not being done as per the facility practice/policy of one bath weekly for each person in care. The Manager will be sending the Licensing Officer an updated Health and Safety plan as a result of this ongoing challenge.
      • 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)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): It was observed that documentation for two person in care's restraint monitoring had not been completed as per directions on the care plan.
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): As per the comments made in this inspection report below, it is apparent that the systems the Licensee has put in place for auditing and self-monitoring the facility operations, and care and services provided remain ineffective at ensuring the facility operates in compliance to the Act and Regulations. It is also apparent the plan put into place as a result of the last inspection (June 7, 2018) has been ineffectively monitored to ensure the plan was effective in gaining/maintaining compliance.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): During this visit, personal care products (hair combs, nail clippers, shampoo bottle) in the bathing room across from 1EF unit found to not be stored separately to reduce potential of the spread of communicable diseases or illnesses.
      • 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): It was observed that multiple "negotiated risk agreements" for persons in care had not been reviewed/assessed and updated as part of care plan reviews. One risk agreement related to diet textures was noted to be dated 2015 with no review or assessment dates noted.
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  39. Monitoring

    0 infractions