Terry's Place
485 Carlstrom Rd Barriere BC V0E 1E0 · Residential Care - Licensing
11 inspections
- Routine Inspection
1 infraction
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): Monthly weights for all persons in care reviewed. Found that weights for all persons in one month were not obtained and reason for not obtaining them was not documented. When persons in care weights are not completed on a monthly basis, this increases the risk of medically related illness for persons in care. Submit an action plan outlining how the Licensee will ensure that all persons in care are weighed on a monthly basis, or a reason recorded for why a weight is not obtained, no later than April 16, 2026.
- R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
- R4.1 - Are person in care records current, complete and kept confidential?
- Routine Inspection
1 infraction
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): The Licensing Officer reviewed person in care's medication administration records, and found two PRN (as needed) medication effectiveness entries were not recorded. When staff do not document PRN medication effect for medications administered there is potential for over administration of an PRN medication. Submit by May 01, 2025, confirmation the monitoring system for medication administration has been reviewed and a plan for continued monitoring and compliance.
- R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Routine Inspection
3 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Upon arrival to the facility, there was construction work occurring onsite, which no health and safety plan had been submitted to Licensing. The manager informed Licensing that the work being done at the time of inspection was a result of another project that had also recently being completed. The manager did indicate that safety had been a priority during the work and all persons in care had been carefully supervised to mitigate risk, even with the oversight by the facility to inform Licensing of the projects.
- R1.1B - Submit plans for the change to licensing and receive written approval prior to making any structural changes; 8( 2 )(a)(i)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): The facility did not have a process which could demonstrate that each day's nutritional needs were sufficient on the menus planned, based on Canada's Food Guide.
- 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 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): In the tub room, there were seven bathing sponges hanging on the wall, above the mopping sink and touching each other. It was confirmed these sponges were labelled for each person in care, but were being stored together, which could lead to cross contamination of bathing equipment.
- 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)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection
1 infraction
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): The posted menu was reviewed and there was only one food group per snack on a daily basis.
- 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)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Routine Inspection
0 infractions
- Routine Inspection
2 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Ensure when a PIC refuses a medication, it is noted in the MAR. Inform licensing on how this will be audited to ensure staff compliance.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): New staff are receiving their initial performance reviews, but performance reviews for regular staff are currently overdue. Please inform licensing on how performance reviews will be caught up and remain up to date.
- 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)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
2 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Medication administration records reviewed during this inspection indicated inconsistent practices in regard to PRN charting. Please review PRN charting expectations and inform Licensing on what changes will be put in place including auditing procedures to ensure procedures are being followed.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 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): Recreation plans are in place, however the daily charting observed during this inspection often did not include any information on whether the identified recreation goals or any recreation occurred during the days reviewed. Inform Licensing on what systems are in place to ensure PIC recreation goals are being met including recreation goals within the home and outings away from the facility.
- R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
3 infractions
- RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
- Observation(s): One PIC is able to leave the building independently, ensure the care plan for this PIC includes specifics regarding independent outings (does PIC have ID? How long are they able to leave independently? What are staff to do if PIC does not return at the specified time? etc...). the plan should be developed/reviewed in conjunction with PIC representatives. This infraction was noted during the last licensing inspection and a plan was developed, however a copy of the plan could not be located during this inspection. Inform Licensing that a copy of the care plan is available for staff to review, also include in your response how often the plan is reviewed and how new staff are made aware of the plan.
- RB1.23A - Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Facility has a process in place to monitor the expiry dates of first aid/CPR for all staff, however several regular staff currently have expired first aid/CPR. Inform Licensing on how the facility will meet RCR 43(1)(a), also include in your response how the auditing of staff qualifications will be modified to ensure expiring items like first aid/CPR are renewed prior to expiring.
- 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)
- 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): One PIC is able to leave the building independently, ensure the care plan for this PIC includes specifics regarding independent outings (does PIC have ID? How long are they able to leave independently? What are staff to do if PIC does not return at the specified time? etc...). the plan should be developed/reviewed in conjunction with PIC representatives. This infraction was noted during the last licensing inspection and a plan was developed, however a copy of the plan could not be located during this inspection. Inform Licensing that a copy of the care plan is available for staff to review, also include in your response how often the plan is reviewed and how new staff are made aware of the plan. The care plan for a PIC who leaves independently was not located during this inspection, inform Licensing on what systems and audits are in place to ensure the care and supervision PIC's receive is consistent with the terms and conditions in their care plans.
- R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
- 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
- RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
- Monitoring
3 infractions
- RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
- Observation(s): One PIC in care is able to leave the building independently, ensure the care plan for this PIC includes specifics regarding the outings (does PIC have ID? how long are they able to leave independently? what are staff to do if they do not return at specified time? ...etc). The plan should be developed in conjunction with PIC representatives.
- RB1.23A - Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Floor trim missing in one PIC bedroom, another bedroom has damage to the wall near the bed, the facility manager Terry indicated the facility was aware of both issues but neither were noted on the facilities self monitoring checks as needing repair. Ensure the repairs are completed and that facility self monitoring documentation procedures are updated to include charting on noted issues including plans/dates for planned repairs. Carpeting on the outdoor deck area is lifting and may cause a tripping hazard to PIC's, the facility plans to have the carpet removed in the Spring of 2016 as this area is not used in the winter. Inform Licensing on the date in which this will be completed, ensure items the facility has identified as needing repair are documented on the facility self monitoring audits.
- 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)
- 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): One PIC in care is able to leave the building independently, ensure the care plan for this PIC includes specifics regarding the outings (does PIC have ID? how long are they able to leave independently? what are staff to do if they do not return at specified time? ...etc). The plan should be developed in conjunction with PIC representatives.
- R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
- RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
- Monitoring
3 infractions
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Results of PRN medications are not consistently being documented, this was also noted during the last Licensing inspection. Ensure PRN documentation includes reason and result (when applicable) of medication. Please submit a plan on how this will be monitored.
- Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Large hole in the drywall/wall in dining area, facility already has plans to fix damage as it just happened recently. Inform Licensing when repairs will be completed. Cushion used on commode chair in washroom is showing signs of wear and tear (cracks) which make it difficult to clean/sanitize properly, cushion replaced at time of inspection. Cupboard under the kitchen sink which stores some cleaners was unlocked at the time of inspection, locked at time of inspection. Ensure all potentially hazardous materials are kept inaccessible to PIC's.
- Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): One PIC in care may be at risk for leaving the facility without notifying an employee, ensure any PIC's who may wander have some type of identification that includes the persons name, facility and emergency contact information.
- 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)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Monitoring
5 infractions
- 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Ensure a self monitoring procedure is developed and practiced and recorded on a regular basis.
- Regularly monitor the physical environment and the care and services provided; 61
- 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): Ensure the reason and result of PRN medications is documented in the MAR.
- Establish and review policies and procedures on safe and effective storage, handling and administration of medications; 68(3)(b)(i)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Information regarding staff qualifications and training not available for all staff, If staff files stored offsite ensure checklist available which includes: Valid criminal record check, CPR/First Aid, reference checks, TB screening, immunization history including flu shots, performance evaluations, resume/certificates.
- Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37(1)(d)
- 4.6 Are facility records current and complete?
- Observation(s): Current menu plan discussed with Manager, all substitutions to menu have not been documented. Licensing discussed options regarding updating menu plans. The facility Manager will review menu plans and ensure all substitutions from menu's are documented in the substitution binder.
- Retain food services records of menus and menu substitutions; 87(b)
- 8.1 Is there an ongoing planned program of physical, social and recreational activities?
- Observation(s): Ensure each PIC's care plan includes recreation activities specific to them and the activities that occur should be charted for review.
- Encourage persons in care to participate in the program of activities provided (Does not apply to Hospice); 55(1)(b)(i)
- 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?