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The Gateby

3000 Gateby Pl Vernon BC V1T 8V8 · Residential Care - Licensing

12 inspections

  1. Routine Inspection

    5 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): The system to ensure that the use of a restraint has a corresponding restraint agreement is ineffective. A review of a Care plan which identified the use of wheelchair seatbelt which the person in care was unable to open, did not have any evidence of a Restraint agreement. Failure to have restraint agreements may compromise the health, safety and dignity of persons in care. Submit by April 10, 2026, the plan that will be implemented to come into compliance with Section 74(1)(b) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • 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): The system to ensure that PRN (as needed) medication administration records are completed is ineffective. A review of the PRN log and medication notes identified missing results / follow-up for the effectiveness of the medication. Failure to document the effectiveness of PRNs can potentially compromise effective medication management. Submit by April 10, 2026, the plan that will be implemented to come into compliance with Section 78(2)(a) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements. The system to ensure that medication administration records are completed is ineffective. A review of Medication Administrative Record's identified missing signatures for the administration of medication, Failure to chart or administer medication as prescribed can potentially affect the health and safety of persons in care. Submit by April 10, 2026, the plan that will be implemented to come into compliance with Section 78(2)(b) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements. This was also a contravention on the previous inspection.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The system to ensure that restraint monitoring is completed is ineffective. A review of a restraint documentation, identified the use of a restraint and monitoring requirements, however, the monitoring sheet identified that monitoring had not taken place for several days. The use of a restraint without consistent monitoring increases the risk to the person in care's physical safety and emotional dignity. Submit by April 10, 2026, the plan that will be implemented to come into compliance with Section 84(d) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system to ensure that persons in care are weighed monthly is ineffective. During a review of person in care's records, the monthly weights are noted to be inconsistently documented. The records do not currently contain any additional documentation to indicate any reason for the missing monthly weights (e.g., refusal, absence, equipment issues, or clinical rationale). Inconsistent or incomplete weight monitoring increases the risk that significant changes in person in care's health status may go unrecognized or unmanaged. Missing documentation can delay timely assessment and intervention, potentially compromising the safety and well being of the person in care. Submit by April 10, 2026, the plan that will be implemented to come into compliance with Section 83(4)(a) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system to ensure persons in care maintaining their hygiene is ineffective. A review of the bathing schedule identified missed baths. The records do not contain any additional documentation to indicate any reason for the missed baths (e.g., refusal, absence, equipment issues, or clinical rationale). Inconsistent or incomplete bathing increases the risk that significant changes in a person in care's health status may go unrecognized or unmanaged. Submit by April 10, 2026, the plan that will be implemented to come into compliance with Section 54(1) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
  2. Routine Inspection

    7 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system to ensure that medication administration records are completed is ineffective. A review of Medication Administrative Record's (MAR) and Treatment Administration Records (TAR) were found missing dates and/or not signed. Failure to chart or administer medication as prescribed can potentially affect the health and safety of persons in care. This was also a contravention on the last Routine Inspection. Submit by September 26, 2025, the plan that will be implemented to ensure ongoing compliance with Section 78(2)(b) of the Residential Care Regulation.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): During this inspection it was observed the last routine inspection report was not posted. The most recent routine inspection report must be posted to allow persons in care and visitors to review the inspection report. Submit by September 26, 2025, the plan that will be implemented to ensure ongoing compliance with Section 11(1)(b) of the Residential Care Regulation.
      • 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system to ensure that employees are trained in the implementation of emergency plans and use of equipment is ineffective. Unit staff do not have access to a key to over-ride the exit doors should they fail to open during an emergency. The inability to exit the floor in case of an emergency compromises the health & safety of persons in care. Submit by September 26, 2025, the plan that will be implemented to ensure ongoing compliance with Section 51(3) of the Residential Care Regulation.
      • R3.1Z - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system to ensure food is safely stored is ineffective, It was observed that fridge temperatures checks were sporadically missing. Not ensuring that storing of food within the correct temperature range may compromise the health and safety of persons in care. Submit by September 26, 2025, the plan that will be implemented to ensure ongoing compliance with Section 63(1) of the Residential Care Regulation.
      • 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): The system for maintaining the physical environment is ineffective as noted by the observed deficiencies; wall damage and paint peeling off walls throughout the facility. It was noted in one bedroom that the protective edging on a door frame was missing. Light covers on an outside patio were covered in cobwebs. Regular maintenance is important to ensure the ongoing health, safety and dignity of persons in care. This was also a contravention on the last routine inspection. Submit by September 26, 2025, the plan that will be implemented to ensure ongoing compliance with Section 22(1)(b) of the Residential Care Regulation. The system to ensure that all rooms and common areas are maintained in a safe condition is ineffective as evident by uneven and spacing between tiles on the third floor patios. Uneven and spacing between floor tiles pose a potential tripping hazard for person in care. This was also a contravention on the last routine inspection. Submit by September 26, 2025, the plan that will be implemented to ensure ongoing compliance with Section 22(1)(c) of the Residential Care Regulation.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system to respect the personal privacy of each person in care is ineffective. It was observed that posted on bedroom doors were a picture and name of the person in care. The facility has no system in place obtaining consent to post such information. Without consent, the use of a picture and name potentially compromises the privacy of each person in care. Submit by September 26, 2025, the plan that will be implemented to ensure ongoing compliance with Section 53(1) of the Residential Care Regulation.
      • R10.2F - Ensure respect for personal privacy of each person in care, including privacy of each person’s bedroom, belongings and storage area; 53
    • 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): During a review of care plans, it was identified that a care plan for a person in care who are able to leave the building independently do not include details of the leaves or information on what steps to take if the Person in care did not return by the expected time. Care plans for Persons in care who can leave the facility independently must include specific details to support the safe outing and return to the facility. Submit by September 26, 2025, the plan which details what systems will be put in place to ensure all care plans for person in care who can leave the facility independently will be completed and updated as needed. During a review of care plans, it was identified that a care plan for a person in care determined to be at risk of leaving the facility lacked a plan to locate and return to the facility. The absence of specific plans may compromise the health & safety of the person in care. Submit by September 26, 2025, the plan that will be implemented to ensure ongoing compliance with Section 81(3)(f) of the Residential Care Regulation.
      • 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)
      • R10.3G - Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
  3. Routine Inspection

    5 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system to ensure that Medication Administration Records show all medications administered is ineffective as evident by missed signatures or medication not administered as prescribed. This was also observed on the Treatment Administration Records. This was also a contravention on the previous inspection.
      • 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 to ensure that care plans are monitored on a regular basis to ensure proper implementation is ineffective. A review of a care plan identified the use of a lap belt restraint There was no evidence of monitoring or completing daily checks as required in 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system to ensure that monthly weights are recorded is ineffective as observed during a random chart review, it was identified that several monthly weights were not recorded. This was also a contravention on the previous inspection.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system for maintaining the physical environment is ineffective as noted by wall damage and paint peeling off walls throughout the facility. There was also stains on a ceiling in a dining area and general cleanliness of fridges. The system to ensure that all rooms and common areas are maintained in a safe condition is ineffective as evident by uneven and spacing between tiles on the third floor patio posing a potential unsafe tripping hazard. This was also a contravention on the last routine inspection. The system to ensure all medications are safely and securely stored is ineffective. Medicated cream was located in a person in care’s bathroom. A medication cart was observed to not be secured while unattended.
      • 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)
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(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): The system to ensure that care plans are monitored on a regular basis to ensure proper implementation is ineffective. A review of tray service documentation was not consistent with the corresponding care plan. The tray service agreement had not been renewed with no evidence to suggest it was discontinued.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  4. Routine Inspection

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system to ensure that Medication Administration Records show all medications administered is in effective as evident by missed signatures.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(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 system to ensure that staff follow procedures is ineffective as evident by incomplete signatures under the ‘MRC Initials and Discipline’ in the Care plans.
      • 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 system to ensure that monthly weights are recorded is ineffective as observed by incomplete charting. This was also a contravention on the previous inspection.
      • 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): The system to ensure that all rooms and common areas are maintained in a good state of repair is ineffective as evident by flooring on the third floor common area in a state of disrepair. The system to ensure that all rooms and common areas are maintained in a safe condition is ineffective as evident by spacing between tiles on the third floor patio posing a potential unsafe tripping hazard. This was also a contravention on the previous inspection.
      • 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)
  5. Routine Inspection

    8 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): A review of a My Day identified use of a restraint. There was also use of a restraint monitoring sheet but no evidence of a restraint agreement in the Care plan.
      • 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 Administration Records were observed during this inspection, PRN effectiveness was noted to be sporadically charted.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): A review of a My Day identified use of a restraint but no documentation referring to the type or duration of the restraint was noted in the Care plan.
      • R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The most recent routine inspection was not posted at the time of this inspection. Report that was posted was from an inspection in 2018.
      • 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): Facility had brochures and information posted about expressing concerns to Patient Care Quality Office but no information on how to express concerns or make complaints to Licensing.
      • R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Recorded monthly weights observed to be charted sporadically. This was also a contravention on the previous inspection.
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The monitoring of fridge temperatures located in the dining areas is ineffective, as indicated by several missed days not recorded. This was also a contravention on the previous inspection.
      • 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): Third floor patio's observed to have uneven flooring tiles as well as spaces between tiles posing a potential tripping hazard. Dining area’s had a daily posting of the menu but not a weekly menu.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
  6. Routine Inspection

    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): Policy for monitoring post fall neurovitals is not accurately followed by employees.
      • 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 system in place for documenting the monthly weight of person's in care is ineffective and there is not a process in place to document a person in care's refusal to be weighed.
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The monitoring of temperatures in the refrigerators located in the dining areas, used for person in care's personal food items, is inconsistent. There is no system in place to regularly monitor the labelling of names and dates on food stored or to remove food after 3 days of storage have passed.
      • 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): It was observed that 4 week menu plans were not posted in dining areas.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
    • 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): Resident Day documents used to guide employees on care and supervision of person's in care were not consistent with care plans. -missing AGG, purple dot, alert. -missing restraint monitoring schedule. -missing behaviour triggers and interventions.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  7. Monitoring

    1 infraction

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The lock was broken on a cupboard in the kitchen area on the second floor. The cupboard contained cleaning supplies and due to the broken lock, the cupboard could be accessed by persons in care. Two biohazard sharps containers were found in one of the dining rooms on the third floor. One sharps container was empty and one sharps container had discarded syringes in it. One of these syringes was on top of the pile of discarded syringes of which could be easily retrieved out of the container. Both sharps containers were removed from the dining room and placed in the medication room. This item was corrected during the inspection.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • 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)
  8. Monitoring

    2 infractions

    • RB1.18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): As noted previously in the inspection report: A person in care who has been identified as a wandering risk did not have the facility phone number provided on the identification information carried by the person in care. This item was corrected during the inspection.
      • RB1.18A - Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): A person in care who has been identified as a wandering risk did not have the facility phone number provided on the identification information carried by the person in care. This item was corrected during the inspection.
      • 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)
  9. Monitoring

    6 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system for ensuring compliance with person in care records is ineffective. There were several missed signatures on the Treatment Administration Record for regularly scheduled treatments. The effectiveness of the PRN treatment creams is documented. Although there is improvement since the last inspection, this remains outstanding from previous inspections.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): The system for ensuring compliance with restraint monitoring is ineffective. The monitoring safety checks are not always documented while a restraint is being used or removed. This remains outstanding from previous inspections.
      • Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
    • 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): As previously noted in the inspection report: There was no documentation noted for the approval of ongoing room tray service by the Medical or Nurse Practitioner. There was also no documentation noted on the reassessment of ongoing room tray service by the Medical or Nurse Practitioner or Dietician at least once every 30 days.
      • Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): There is a new Manager in place as well as a new Residential Care Coordinator. There is a plan in place for the completion of performance reviews. This item remains outstanding from previous inspections.
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): The system for ensuring compliance with person in care records is ineffective. There were several person in care records on the Pathways to Home Program that did not have height, weight, eye color, hair color or picture. Missed monthly weights were noted on several person in care records.
      • 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)
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There was no documentation noted for the approval of ongoing room tray service by the Medical or Nurse Practitioner. There was also no documentation noted on the reassessment of ongoing room tray service by the Medical or Nurse Practitioner or Dietician at least once every 30 days.
      • 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)
  10. Monitoring

    8 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): A sampling of medication and treatment records were reviewed. There were several missed signatures noted on the Treatment Administration Record. The manager stated that audits are being completed and follow up in regards to reviewing of the treatments and orders will take place. This remains outstanding from previous inspections.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): Safety monitoring checks are not always being completed or documented correctly on the restraint monitoring record. This remains outstanding from the previous inspection report.
      • Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
    • 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): Policy and procedure on self administration of medication for persons in care was not followed. The Medication Safety and Advisory Committee was not involved and and there was no monitoring plan for compliance or monitoring of the ability to continue to self medicate being completed or documented in the care plan.
      • 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): The manager stated that performance evaluations are continuing to be completed on a monthly basis with the goal for employees requiring their evaluation per policy being June 1, 2016. This item remains outstanding from previous inspections.
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): A sampling of person in care charts were reviewed during the inspection. Consents were on file for the Pathways to Home clients but one consent from a respite client was not on file.
      • 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)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Damage noted to dining room wall on Second South and wall damage noted to hallway entrance of a persons in care room on the third floor. Water damaged shelving was being stored on one of the patio decks. The one side of the shelf leaning up against the patio railing had nails sticking out. This item requires follow up by April 13, 2016. Several person in care rooms were inspected and two person in care bathroom cupboards were found to be unlocked with prescription treatment creams accessible. The cupboards were locked by a staff member during the inspection. This item was corrected during the inspection.
      • 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)
      • Ensure all medications are safely and securely stored; 69( 3 )(a)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): Self administered medications were not recorded on the persons in care Medication Administration Record.
      • Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
    • 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): A sampling of person in care records were reviewed during the inspection. It was noted that restraint monitoring was taking place and consents for the restraint were obtained. There was no indication on the care plan that the specific restraint was being used.
      • 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. Monitoring

    10 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): There were several missed signatures noted on the Medication Administration Record for regularly scheduled medications. This remains outstanding from several previous inspections. There were several missed signatures noted on the Treatment Administration Record for regularly scheduled treatments. This remains outstanding from several previous inspections.
      • 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): Immunization screening is not being completed on the Pathways to Home Program. There is a document in the Kardex which has and area designated for immunizations, but the sampling of records reviewed showed these areas were left blank. This remains outstanding from past inspections.
      • 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): An electrical cord was noted on the floor and accessible to persons in care in one of the dining/lounge areas. The electrical cord could potentially be a trip and fall hazard.
      • Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): Safety monitoring checks are not always documented on the monitoring record. Checks were not documented for several hours and the monitoring record indicated the restraint was still in use and had not been removed.
      • Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Several infractions from the previous inspection were found to be unresolved. Self monitoring and devising of audit tools were discussed with the manager.
      • 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): Temperature readings of the medication fridge are noted daily but the policy indicates twice a day. There were several missed second temperature readings noted for the month of October and November. The medication fridge contained a vial of the flu vaccine. This item remains outstanding from past inspection report. The effectiveness of PRN medications is not always documented on the Medication Administration Record.
      • 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): The staffing spread sheet does not include performance evaluations. The manager stated that there is a computer reminder program in place for when employees evaluations are due but stated that evaluations are overdue at this time. This remains outstanding from the previous inspection.
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Financial agreements are signed for the Pathways to Home Program but there are no written consents on file to call a medical or nurse practitioner or ambulance in case of accident or illness
      • 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)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): One of the corners of the portable servery barricade noted to be damaged with an uneven sharp edge. Wall damage noted to a resident bathroom located across from the nursing station on the second floor. Follow up for this item is to be completed by Dec. 11, 2015
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The Pathways to Home Program may have persons in care in the program for over 30 days. In the sampling of records reviewed today, it was noted that one person in care had been in the facility for over 30 days without a nutritional care plan in place.
      • 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)
  12. Monitoring

    11 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): There were several missed signatures for regularly scheduled medications noted on the Medication Administration record. This remains outstanding from the past two inspection reports. There were several missed signatures for regularly scheduled treatments noted on the Treatment Administration Record. This remains outstanding from the past inspection report.
      • 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): Unable to locate evidence of immunization screening for the persons in care residing in the Pathways to Home program. TB screens are being completed upon admission but immunization screening is not. This remains outstanding from the last inspection.
    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Garden hoses noted to be on the ground by the door of several patio areas. The garden hoses do not have holders and are laying on the ground posing a tripping risk to persons in care.
      • Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): Safety monitoring checks are not always being documented on the monitoring record. Checks were not documented for several hours and the record indicated that the restraint was in use and not removed. This was noted on several person in cares restraint monitoring records. It was indicated on one of the restraint care plans that the Occupational Therapist was to review the restraint on a quarterly basis. The restraint was scheduled to be reviewed in February of 2015 and in reviewing the documentation on the chart the restraint was not reviewed until May of 2015.
      • Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
      • Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): As noted previously on inspection report. Medication Administration Record being stored on top of the medication cart in one of the dining rooms. This remains outstanding from the last inspection.
      • Respect personal privacy and keep records and personal information confidential.
    • 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): Monitoring of the medication fridges are to be done twice a day as per the policy/protocol attached to the binder for the medication fridge temperature monitoring. Several inconsistencies were noted with the monitoring of the temperatures.
      • 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): The spread sheet provided by the facility does not include reference checks. The spread sheet provided by the facility does not include work history. The spread sheet provided by the facility does not include copies of diplomas, certificates or other evidence of training other than food safe for those staff requiring food safe. The spread sheet provided by the facility only contains evidence of the tuberculosis screening and not immunization screening. The facility does not keep any employee files on site and the staffing spread sheet does not include performance evaluations. The manager stated that she is behind in completing performance evaluations. It was noted during the inspection that two staff noted to have expired first aid certification. Follow up date for this item is July 15, 2015. Fire drills for the staff noted to be missed on several occasions since the last inspection. Fire drills are to be conducted monthly. The follow up date for this item is June 30, 2015.
      • Obtain character references for all employed persons; 37( 1 )(b)
      • Obtain a record of work history for all employed persons; 37( 1 )(c)
      • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37( 1 )(d)
      • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
      • Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
      • Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 7 )
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): The Medication Administration Record is being kept on top of a medication cart in one of the dining areas. The Medication Administration Record was open with confidential information accessible to passers by. This was noted on the Bill of Rights during the last inspection and remains outstanding.
      • 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): Damage noted to counter top trim in several of the dining/kitchen areas. This has been discussed with the Maintenance man on each inspection. The Maintenance man stated that funding has just been secured for this project with the plan of hiring subcontractors to complete new counter tops. This item has been outstanding on several inspection reports and a date of completion set for December 15, 2015. An electric shaver was noted to be plugged in and left on the counter by the sink in the bathroom of a person in care with the shaver accessible and in reach of the person in care. The shaver was moved back an out of reach during the inspection. Cupboards underneath sink in kitchen areas noted to be unlocked with cleaning supplies accessible to persons in care. Several of these cupboards were locked during the inspection but some remained unlocked. Follow up for this item to be completed is June 12, 2015. Treatment creams and eye drops were found unlocked in the bathroom cupboards of two person in care rooms. One of these cupboards was locked during the inspection. The follow up date for this item to be to be completed is June 12, 2015.
      • 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)
      • Ensure all medications are safely and securely stored; 69( 3 )(a)
    • 10.1 Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): Unlabeled toiletries such as hair brushes and disposable razors were noted in one of the bathing rooms. The hairbrushes and disposable razors were noted to be on the counter of the bathing room and several disposable razors as well as fingernail clippers were stored on the shelf in the cupboard. These personal items were not labelled or stored in personal use containers. This item remains outstanding from the past inspection report.
      • Promote the health, safety and dignity of persons in care; CCALA 7( 1 )(b)(i)
    • 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): A sampling of care plans of persons in care were reviewed during the inspection and several care plans have not been reviewed in over 1 year. These care plans included falls prevention plans from the RAI.
      • 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)