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Sunnybank Centre

6553 Park Dr Oliver BC V0H 1T0 · Residential Care - Licensing

19 inspections

  1. Routine Inspection Follow-up

    0 infractions

  2. Routine Inspection Follow-up

    1 infraction

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): It was determined that concerns regarding allegations of abuse were received by the manager several weeks before the incident report was submitted to Licensing. Failing to complete an incident report regarding allegations of neglect and abuse may cause a risk to the health and safety to persons in care as Licensing is unable to also assess the reports. Reporting also provides required documentation which may be referred to if a complaint regarding the allegations are received. Submit by November 7, 2025 evidence that there is plan in place to ensure that all staff are aware of the reporting requirements related to allegations of neglect and abuse.
      • R4.5C - Report when a person in care is the subject of emotional, physical, financial or sexual abuse or neglect; 77(1)(a)(ii)
  3. Routine Inspection

    1 infraction

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing observed a step ladder left unattended in a hallway which was accessible to persons in care. Ensuring maintenance items/tools are not accessible to persons in care reduces the risk of potential falls or the item being used in an unintended manner. The ladder was removed and an action plan correcting the contravention was accepted by Licensing during the inspection.
      • 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)
  4. Routine Inspection

    2 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): Licensing Officer observed a recliner that was not maintained in a good state of repair. The contravention was corrected during the inspection.
      • R7.2N - Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(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): Licensing Officer reviewed an incident where a nutritional care plan was not properly implemented by staff. A corrective action plan was implemented by the Licensee, therefore the contravention has been resolved.
      • 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
  5. Routine Inspection

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing Officer did not observe the manager's name prominently displayed. This was corrected during the inspection. Licensing Officer reviewed the monitoring processes at the site as per Residential Care Regulation 61. Licensing was informed in a corrective action plan that a monthly audit would be occurring and the checklist would be available upon request. During the inspection it was noted that this audit process was no longer occurring as previously submitted and accepted by Licensing.
      • 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)
      • R1.1W - 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): Licensing Officer reviewed the monthly weight records which were not being recorded as per the policy and procedures.
      • 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): Licensing Officer reviewed a care plan for a person in care which contained outdated information, therefore not ensuring compliance with Residential Care Regulation 82.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  6. Routine Inspection Follow-up

    6 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Since the previous inspection on February 6, 2024, Licensing has received twenty-two incident report submissions. Of those, twelve required follow-up for additional information. There have also been three Service Delivery Problem incident reports which were not immediately submitted to Licensing. One was submitted five days after the incident occurred and the other two were submitted three days after the incidents occurred.
      • 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 contravention listed under R4.5 has been found in non-compliance in the previous four routine inspections. The contravention under R10.2 has been found in non-compliance during the previous two inspections. The reoccurring contraventions indicate ineffective monitoring processes.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing Officer observed a freezer used for person in care's food where the temperature was not being monitored.
      • 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): Licensing Officer observed a fire extinguisher with no evidence that it had been maintained or inspected on a regular basis.
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Licensing Officer reviewed four care plans for persons in care, one had approval and was reassessed as per the Regulation but was not mentioned in the care plan.
      • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Licensing Officer reviewed four care plans, one of which required a plan for behavioral intervention but was not included in the care plan. Licensing Officer reviewed a care plan that contained a medication administration directive that was contrary to the directives in a signed managed risk agreement. Licensing could not ensure the care and supervision was consistent with the terms and conditions given the opposing directives.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(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
  7. Routine Inspection

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Approximately half of the incident reports received by Licensing in December of 2023 and January of 2024 were not completed in the manner or form 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): Licensing Officer observed the most recent routine inspection record was not displayed in the facility. This was corrected during the inspection. Licensing Officer did not observe a monitoring system to ensure compliance for Residential Care Regulation 77(2)(c) and 63(3)(c). Please see R4.5 and R10.2 for further information.
      • 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)
      • R1.1W - 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): Licensing Officer observed two charts for persons in care. Both of the charts had multiple pro re nata (PRN) medications charted contrary to facility policy. In these instances, PRN medications were either charted solely for effectiveness and not signed on the Medication Administration Record (MAR) or signed on the MAR but not documented for effectiveness.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Licensing Officer observed the four week menu. For each week, there were three snacks which did not contain two food groups.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Licensing Officer did not observe the approval or reassessment required for ongoing tray service.
      • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
  8. Routine Inspection

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Licensing Officer observed an incident detailed in a chart that was not reported to Licensing as required.
      • R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • 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): Licensing Officer reviewed three person in care's charts, the admission separation form was not completed in two instances but was completed on the third.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing Officer observed four person in care's charts, one of which was recording the monthly weights as required by the Regulation and the other three were not. Licensing Officer observed a wound assessment form that was left unattended in a hallway.
      • 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)
      • R4.1S - Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing Officer observed one emergency exit that was completely obstructed and two other exits that were partially obstructed, all of which may hinder an exit in an emergency. Licensing Officer observed a pair of scissors which was accessible to persons in care and not securely stored. Licensing Officer observed that the weekly menu was not posted as required.
      • R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
      • 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 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Licensing Officer observed a chart describing tray service for a person in care which was missing required items as per the Regulation.
      • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
  9. Routine Inspection

    7 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Licensing is not receiving reportable incidents in the manner required. The Licensing Officer observed an incident (unexpected illness) that was not reported to Licensing as required. Licensing Officer has received 18 reportable incidents in 2023, 8 of which were missing 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): The was no system to monitor the fridge temperature tracking checklist to ensure it was properly implemented by employees. The Licensee's system to monitor reportable incidents for their content and to ensure they are properly submitted to Licensing is ineffective.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Licensing Officer reviewed three care plans, each contained documents that were incomplete, contrary to facility policy. Licensing Officer spoke with three staff members (two within leadership), each identified that they were not orientated to the Residential Care Regulation and the Community Care and Assisted Living Act.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing Officer observed three 2023 monthly weight records for persons in care (January, February, and March). One was missing a weight for January and another was missing weights for January and February.
      • 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)
    • R4.6 - Are facility records current and complete?
      • Observation(s): Licensing Officer observed outdated COVID19 signs at the front entrance. This was corrected during the inspection.
      • R4.6L - Ensure all records are current; 91( 1 )(a)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Licensing Officer was verbally informed there are monthly facility visits from the pharmacist but there was no documentation pertaining to a medication safety and advisory committee, nor was there any records of the last committee meeting and their findings.
      • R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)
    • 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): Licensing Officer observed a care plan that contained differing information. Licensing Officer observed three care plans for persons in care, two of which did not contain nutritional care plans.
      • 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)
      • R10.3M - 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
  10. Routine Inspection

    6 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The Licensee's system to ensure that reportable incidents are submitted in compliance with the legislation was noted to be ineffective. A review of the facility file indicated that multiple incident reports are submitted monthly and it was observed that there had been no incident reports submitted for the month of December. Upon further inspection of three incidents submitted to the internal incident reporting system it was noted that one should have been submitted as an incident report to 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)
    • 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's system for ensuring that employees follow policies and procedures for the administration of medication was noted to be ineffective. During the inspection two persons in care's medication administration records (MAR) for the month of December 2022 were observed. One MAR was missing three signatures and the other MAR was missing four signatures where medications should have been administered as per their prescription. When observing the same two MARs it was found that on one MAR, ten out of fifty-four PRN medication administrations did not have the effectiveness documented and on the other MAR twelve out of thirty-five PRN medication administrations did not have the effectiveness documented.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The Licensee's system for ensuring documentation of height and weight upon admission is ineffective. During the inspection it was observed that the height and weight of a person in care at the time of admission was not documented on the admission form or the monthly weight form. This was also discussed on the June 28, 2022 routine inspection.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Licensee's system to ensure that snacks are provided in compliance with the legislation was noted to be ineffective. During the inspection four days of snack menus were observed and three of those days had only one food group offered.
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The Licensee's system to ensure secure storage of records was noted to be ineffective. During the inspection it was observed that an office door containing person in care charts was left open and unattended.
      • R7.1AJ - Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee does not currently have a system in place to ensure that all persons in care leaving the facility are provided with identification as per the legislation.
      • 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)
  11. Substantiated complaint

    2 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Investigation Findings - It was found during the investigation that Licensing was not immediately notified when a person in care was transferred to the hospital for an Unexpected Illness.
      • R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Allegation - The licensee is in non-compliance with Residential Care Regulation 54(1). Investigation Findings - It was found during the investigation that there was a period of 12 days and another period of 23 days, where there was no documented evidence of bathing or an offer of bathing for a person in care. The allegation was found to be substantiated.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
  12. Substantiated complaint

    1 infraction

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Allegation - The licensee is in non-compliance with Residential Care Regulation 76(1). Investigation Findings - It was found during the investigation that the representative or contact person was not immediately notified of an illness pertaining to a person in care. The allegation was found to be substantiated.
      • 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 )
  13. Routine Inspection

    6 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Licensing Officer observed that the Licensee had no records of previously submitted incident reports to Licensing.
      • R4.5J - Retain a record of reportable incidents involving persons in care; 88(c)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Licensing Officer observed three charts for persons in care. Of those three, two did not comply with the Province's immunization and tuberculosis control programs.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing Officer observed that the most recent routine inspection record was not posted in the facility.
      • 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)
    • 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): Licensing Officer observed two persons in care's medication administration records (MAR) for the month of May, 2022. One MAR was missing ten signatures, the other was missing nine signatures where medications should have been administered as per their prescriptions. Licensing Officer observed on these same two Medication Administration Records (MAR) that the PRN effectiveness was not being charted as per facility policy. One MAR had fourteen out of thirty PRN's not charted properly, the other had twenty out of twenty-six that were not charted properly. Licensing Officer observed that there was no procedure or policy for submitting incident reports to Licensing. Licensing Officer saw no confirmation that prior to admission, the person, parent, or representative was given information on how to express a concern or make a complaint to the Patient Care Quality Review Board Act or Licensing.
      • R2.1D - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to the Patient Care Quality Review Board Act; 48( 1 )(c)(ii)
      • 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)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing Officer observed a refrigerator that contained items for persons in care where the temperature was not being properly monitored.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 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): Licensing Officer observed three charts for persons in care. One of the three care plans was not updated as per Residential Care Regulation 81(4)(b).
      • 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)
  14. Routine Inspection

    3 infractions

    • R4.1 - Are person in care records current, complete and kept confidential?
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Upon request, there is no record of menu substitutions.
      • R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 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): Two oral care plans are not on record and some others were missing information to ensure that it continues to meet the need and preferences of each person in care according to Section 81(4)(b)(ii).
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  15. Monitoring

    2 infractions

    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Upon review of care plans, the Licensing Officer could not locate the weight upon admission for two persons in care. The Licensing Officer unable to locate the photograph and a record showing information to identify the person in care in case of an emergency when reviewing care plans.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): One person in care's bathroom walls are damaged near the floor moulding (drywall gouged, paint peeling, potential water damage). In the outdoor area, along the walkways, there are benches for persons in care to sit and rest on which have peeling paint and the wood showing the affects of weather damage (rough surface). The outdoor concrete walkways have gaps between each section where it appears wood inserts used to be, which made them level to each other. These gaps have been noted to catch person in care's walker wheels, creating a trip and fall hazard. In some areas the gaps are also uneven, which also presents a trip and fall risk to persons in care as well. In the large outdoor gazebo, the Licensing Officer observed a broken table leaning against the wall, a chair with plastic strapping missing a cushion, and the BBQ propane tank exposed and accessible to persons in care. One emergency exit observed to be partially obstructed by a floor lift and a wheelchair being stored in this area. In one bathing room, personal care products (shaving cream) not labelled to identify who it belongs to, nor stored separately to reduce potential of the spread of communicable diseases or illnesses.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
      • 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)
  16. Monitoring

    2 infractions

    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Upon review of person in care's care plans, photographs were in place. See above comment (R3.1).
      • R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): A managed risk agreement is in place and signed for ongoing tray service for persons in care; however, unable to locate the doctor's order or reassessment documentation.
      • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
  17. Monitoring

    6 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): It was noted that prn effectiveness was not always documented as per medication administration requirements. This is a re-occurring infraction (noted on the May 21, 2015 monitoring inspection report).
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): The 'rehab'/lounge room still does not have a signalling device available to staff or persons in care in case of emergencies. This infraction was noted on the previous monitoring inspection (dated December 22, 2015). When discussing this with the Manager, she indicated that there was a plan in place to have it installed in the near future. Please provide this plan to Licensing in writing.
      • Ensure controls for signalling devices, lights and elevators are accessible and easy to use; 14 ( 3 )
    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): May 21, 2015-It was noted that the facility was not following it's policy for the storage of medication as unlocked medications were located in two resident's rooms. This infraction is still considered unresolved - please refer to comments in this report.
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): The monthly weights of persons in care were not consistently being monitored or recorded. It was observed that private medical information (such as allergies, diet type, "diabetic") for persons in care was in areas of public view at the time of inspection. For example: 1) there were labels on the edges of dining room tables identifying the person in care's name and medical condition; 2) person in care's names and allergies were on a sheet of paper stuck to the front of a fridge in the servery area adjacent to the dining room where visitors and other persons in care have free access.
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
      • Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The walls and closet doors were still noted as damaged in some person in care's rooms (paint chipped, gouges and holes) as noted on the previous inspection report dated December 22, 2015. A number of emergency exits throughout the facility were noted to be partially blocked by wheelchairs and walkers. At the time of inspection, it was noted that in multiple person in care's rooms medications, medicated creams and supplements were stored accessible to persons in care. Throughout the facility, it was observed that "Cavi-wipes" are stored accessible to persons in care. In addition, the recreation/activities fridge where alcohol is stored was left unsecured at the time of visit.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
      • Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It was noted that the care plans for persons in care are in need of monitoring and review in order for the Licensee to ensure the person in care's needs are being met. Multiple person in care's care plans identify specific managed risk agreements, behaviour care plans, restraint agreements, and transfers/positioning directives; however, no evidence is present to indicate this monitoring or reviews are being completed as directed (or required).
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  18. Monitoring

    6 infractions

    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): The 'rehab'/lounge room does not have a signalling device available to staff or persons in care in case of emergencies.
      • Ensure controls for signalling devices, lights and elevators are accessible and easy to use; 14 ( 3 )
    • 8.2 Does the program of activities support individualized care plan requirements?
      • Observation(s): At the time of inspection, it was observed that the Activities staff have a varied and active recreation and social program within the facility. However, the Licensing Officer was unable to determine whether the program of activities is suitable to the needs or meet the objectives for a person in care, as individual care plans do not include information regarding recreation and leisure.
      • Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55( 1 )(a)(ii)
    • 13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): The Licensing Officer was unable to determine whether the program of activities is suitable to the needs or meet the objectives for a person in care, as individual care plans do not include information regarding recreation and leisure.
      • Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): One black tool box used for storage of medicated creams and drops was left unsecured. This tool box was located on a supply cart in the main hallway adjacent to person in care's rooms. This is a re-occurring infraction of the facility/staff not following the Licensee's medication storage policies.
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It was noted that some person in care's rooms and main dining room have minor damage on walls (chipped paint and drywall). One black tool box used for storage of medicated creams and drops was left unsecured. This tool box was located on a supply cart in the main hallway adjacent to person in care's rooms.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Ensure all medications are safely and securely stored; 69( 3 )(a)
    • 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Persons in care's care plans missing information regarding oral health care. Persons in care's care plans do not include information regarding recreation and leisure.
      • Care plans must includes an oral health care plan; 81( 3 )(b)
      • Care plans must include a recreation and leisure plan; 81( 3 )(d)
  19. Monitoring

    12 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): OUTSTANDING from March 19, 2014 -It was noted that prn effectiveness was not always documented as per medication administration requirements.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): May 21, 2015 - It was noted that some Resident's charts did not contain immunization screening.
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): OUTSTANDING from March 19, 2014 -It was noted that some outdoor benches in the front of the facility were rough with chipped paint (Noted: the benches in the courtyard had been re-painted)
      • Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • 16 - Are persons in care who make prepayments provided written terms and conditions under which a refund may be made?
      • Observation(s): Information was submitted to Licensing reporting the development and implementation of a repayment agreement.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): May 21, 2015- during inspection it was discovered that the manager had resigned, and it had not been reported to Licensing. Licensing received notification on May 22nd that there was an interim manager.
      • Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): May 21, 2015- It was noted that the emergency fan-out list contained the name of the retired manager. May 21, 2015-It was noted that the facility was not following it's policy for the storage of medication as unlocked medications were located in two resident's rooms.
      • Update emergency plans if there is any change in the facility; 51 ( 6 )
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): OUTSTANDING from March 19, 2014 -Incomplete staff files May 21, 2015 - the Manager was not present at the time of inspection and the staff files could not be accessed. The staff files will be reviewed during the next inspection.
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): OUTSTANDING from March 19, 2014 -It was noted that some Resident's charts did not contain admission height and weight. -It was noted that some Resident's charts did not contain immunization screening. -It was noted that some Resident's charts did not contain consent as per RCR 78(3)(a). NEW INFRACTION from May 21, 2015 -It was noted that confidential Resident information was posted on the dining room tables.
      • Record the height and weight of each person in care on admission; 49 ( 6 )
      • 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
      • Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
      • Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): May 21, 2015 -It was noted that one tub room contained a bin with unlabeled nail clippers and unlabeled creams.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 5 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): OUTSTANDING from March 19,2014 - It was noted that some Resident's rooms had chipped paint and corners. - It was noted that the paint was chipped in some areas of the dining room. (Noted: impact board had been installed on the walls in some areas of the dining room) NEW INFRACTIONS from May 21, 2015 - It was noted that some Resident's rooms had damaged walls and/or torn wallpaper. -It was noted that an area of the outdoor lounge area was being used to store fridges that were not in use. -It was noted that some Resident's rooms contained prescription medications that were unlocked and accessible to Residents. This requires immediate follow up on the part of the facility.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Provide comfortably furnished lounge areas; 34 ( 1 )( 2 )(a)
      • Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): OUTSTANDING from March 19, 2014 - It was noted that the medication administration record was not always signed to indicate whether it had been administered or not.
      • Administer only medications prescribed or ordered by the medical or nurse practitioner; 70 ( 5 )
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): May 21, 2015 -It was noted that one care plan in regards to room tray service had not been updated within the past year.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 5 )
      • Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)