Skip to content
Loading map…

Villeneuve House

1400 Cherry Crescent E Kelowna BC V1Y 3Y3 · Residential Care - Licensing

17 inspections

  1. Routine Inspection

    3 infractions

    • R4.6 - Are facility records current and complete?
      • Observation(s): It is observed that some information in a person in care chart is outdated regarding staffing, a facility recreation plan, and behaviours of current persons in care. Outdated information may increase risk to persons in care by leading to inappropriate care decisions, communication errors, or failure to provide care consistent with current needs and supports. Submit to Licensing by July 10, 2026, a plan outlining how all records will be current as per legislative requirements. The plan must identify the steps that will be taken to achieve compliance, as well as the measures that will be implemented to ensure ongoing compliance.
      • R4.6L - Ensure all records are current; 91( 1 )(a)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It is noted that a fence in the backyard is constructed in a manner that exposes sharp metal edges. These sharp edges have the potential to cause injury to persons in care who come into contact with them. Submit to Licensing by July 10, 2026, a plan outlining how the outdoor space, specifically the metal fence, will be safe for all persons in care. The plan must identify the steps that will be taken to achieve compliance, as well as the measures that will be implemented to ensure ongoing compliance.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): It is observed that some PRN (as needed) medication bottles do not have a pharmacy label affixed. Pharmacy labels provide important information and the absence of pharmacy labels may increase the risk of medication errors, including incorrect administration. Submit to Licensing by July 10, 2026, a plan outlining how all medications will be packaged or labelled as per legislative requirements. The plan must identify the steps that will be taken to achieve compliance, as well as the measures that will be implemented to ensure ongoing compliance.
      • R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
  2. Routine Inspection

    2 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): 61 - The Licensee's system to ensure that the physical environment and the care and services provided is monitored was found to be ineffective as per the contraventions noted in this inspection report. Regular monitoring of the physical environment and the care and services provided is required to ensure the needs of persons in care are being met and re-evaluated to ensure the health, safety and dignity of persons in care. Submit by May 14, 2025, a plan outlining a system to ensure regular monitoring of the physical environment and the care and services provided, as noted in this report. The plan must include a system to ensure ongoing compliance.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): 23(2)(a) - The Licensee does not have a system in place to ensure that no one other than a person in care engages in a restricted activity while on-site. During the inspection, discussions regarding smoking were had and it was determined that employees smoke while on-site. Employees smoking on the premises of the facility may increase risk to persons in care if their care needs cannot be attended to as required. Submit by May 14, 2025, a plan outlining the system to ensure that no person other than a person in care engages in a restricted activity while on site. The plan must include a system for monitoring to ensure the care needs of persons in care are being met. 23(2)(c) - The Licensee does not have a system in place to ensure persons in care are assessed to ensure they are able to safely smoke without supervision. During the inspection, it was noted that care plans include plans for smoking; however, the plans do not include any assessments outlining whether or not a person requires supervision. Not having assessments in place for smoking safety may result in inadequate supervision leading to injury of persons in care. Submit by May 1, 2025, a plan outlining the system to ensure persons in care will be supervised, if necessary, while smoking. The plan must include a system to come into compliance as well as a plan to ensure ongoing monitoring if reassessment is needed. 35(1)(c) - The Licensee's system to ensure hazardous materials are not accessible to persons in care was found to be ineffective. During the inspection, cleaning products were observed to be left accessible to persons in care in a bathroom. It should be noted that there is a closet in the bathroom with a lock to store cleaning agents; however, at the time of the inspection, the closet was noted to be left unlocked and a cleaning agent was observed to be left on top of a cabinet. In this same bathroom it was also observed that a topical medication was left unlocked in the medicine cabinet. The cabinet was noted to be equipped with a lock; however, it was noted to be unlocked at the time of the inspection. The Manager assistant confirmed that it is the expectation that these are to be locked. The items were removed and both the cabinet and closet were locked during the inspection when these observations were brought forward to staff. Hazardous materials being accessible to persons in care presents a risk as they may be ingested or used incorrectly and result in injury or death. Submit by May 14, 2025, a plan outlining how cleaning agents will be securely stored. The plan must include a system for monitoring to ensure employee compliance with the legislative requirements.
      • R7.1M - Ensure that no one other than a person in care engages in a restricted activity while on the premises of the facility; 23(2)(a).
      • R7.1O - Ensure that if necessary for the safety of the person in care, a person in care who engages in restricted consumption is supervised.; 23(2)(c).
      • 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)
  3. Routine Inspection

    6 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): During the inspection, 3 employee files were reviewed and the checklists in 2 of those files were noted to be incomplete. During the inspection, it was also noted that a job description form was not signed as required. These contraventions were both corrected during the inspection.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The Licensee's system to ensure that character references for all employed persons are obtained was found to be inefficient. During the inspection, in 1 employee file, it was noted that only 1 character reference was obtained and that it contained minimal information. The Licensee's system to ensure that employees comply with the policies and procedures of the medication safety and advisory committee (MSAC) was found to be ineffective. During the inspection, it was noted that as needed (PRN) medication was not included on the medication administration record (MAR) but was routinely being administered to the person in care. The MSAC policy and procedure indicates that all PRN medications must be included on the MAR.
      • R3.1C - Obtain character references for all employed persons; 37( 1 )(b)
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • 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 that all medications are safely and securely stored was found to be inefficient. During the inspection, it was noted that 2 medications were not labelled by the pharmacy.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The Licensee's system to ensure that only medications prescribed or ordered by the medical or nurse practitioner are administered was found to be ineffective. During the inspection, it was noted that a topical medication was being administered without a prescription.
      • R9.1E - Administer only medications prescribed or ordered by the medical or nurse practitioner; 70 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee's system to ensure respect for privacy of each person in care was found to be ineffective. During the inspection, it was noted that personal information was displayed in a public area.
      • 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 the inspection, it was noted that one falls care plan had no evidence that it had been reviewed yearly. This was corrected during the inspection.
      • 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)
  4. Routine Inspection

    3 infractions

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Licensing Officer did not observe any evidence that the policies and procedures were reviewed at least once per year.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing Officer (LO) observed gardening equipment that was not securely stored. LO also observed a metal bed that was unattended outside of the facility.
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The system to ensure behavioral interventions are documented in care plans was inadequate. Licensing Officer observed a care plan that was not reviewed or revised after a substantial change.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
  5. Routine Inspection

    5 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Licensing Officer observed two charts for persons in care. One did not have immunization screening while the other did not have tuberculosis screening.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Licensing Officer requested emergency plans that initially could not be located. The plans were eventually located and placed in a prominent place.
      • R2.1I - Display a copy of the emergency plan in a prominent place; 51 ( 4 )
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Licensing Officer observed two staff files, both of which did not contain any performance reviews. One of the two staff files did not contain any immunization screening.
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
      • 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)
    • R4.6 - Are facility records current and complete?
      • Observation(s): Licensing Officer observed a staff file that had an incomplete checklist. This is an outstanding contravention from the previous inspection report.
      • R4.6L - Ensure all records are current; 91( 1 )(a)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Licensing Officer observed a snack menu detailing two snacks per day when there is often an undocumented third snack.
      • R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
  6. Routine Inspection

    3 infractions

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Licensing Officer observed that Licensee did not have written emergency plans that set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures. Licensing Officer observed during the inspection that the Licensee did not have a written facility elopement policy/procedures.
      • R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
      • 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)
    • R4.6 - Are facility records current and complete?
      • Observation(s): Licensing Officer observed a food substitution list that contained records that were not current. Licensing Officer Observed a staff file which contained an incomplete 'New Team Hiring Checklist' form. This was corrected during the inspection.
      • R4.6L - Ensure all records are current; 91( 1 )(a)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Licensing Officer observed a nutritional care plan that did not contain all the necessary information. Licensing Officer observed two binders that contained inconsistent care plan direction for the same person in care.
      • 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
  7. Routine Inspection

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Licensing Officer observed three internal incident reports. One of the incident reports was deemed reportable to Licensing but was never submitted in the manner 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 (LO) found there was no formal elopement policy in place to guide staff. LO observed an elopement form that had not been reviewed/revised at least once a year. LO observed an internal incident report that did not have the necessary signatures contrary to facility policy.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing Officer reviewed three care plans, all three did not have the height recorded upon admission and one didn't have the weight. All three care plans also did not record the person's sex.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • R4.1C - Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78( 1 )(a) Director of Licensing Standards of Practice: Immunization records
    • 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 was missing an oral health care plan.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  8. Routine Inspection Follow-up

    4 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The system in place to ensure the proper use, monitoring, and documentation for restraints is ineffective. LO reviewed the restraint care plans for persons in care. LO observed there were no details on the use of the restraints or it's duration for which they were to be used. LO observed there were no times specified for re-assessment documented in the care plans or restraint agreements.
      • 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
      • R10.4N - 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)
    • 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): A staff file that did not have an employee credential and professional tracker checklist completed, contrary to facility policy. This was completed during the inspection.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): A staff file did not have the immunization screening completed.
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
    • 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 the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan is ineffective. Monitoring equipment and it's usage was not appropriately care planned for. Oral health care plans were reviewed and it was found that a quarterly oral health assessment tool was not completed as described in the care plan. Comment: All new care plans have now been created for all persons in care.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  9. Routine Inspection Follow-up

    6 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system that is in place to ensure reportable incidents are sent to Licensing when a person in care is involved in a reportable incident is ineffective. During the February 23, 2021 inspection, Licensing Officer discussed and reviewed facility files with the manager. LO observed four incidents where persons in care were involved in reportable incidents (i.e.: transfers to hospital) that were not submitted to Licensing. During this inspection, LO reviewed facility files and observed another incident that was reportable to Licensing but was not submitted to Licensing.
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): The system in place to ensure the proper use, monitoring, and documentation for restraints is ineffective. LO reviewed the restraint care plans for persons in care. LO observed there were no details on the use of the restraints or it's duration for which they were to be used. LO observed there were no times specified for re-assessment documented in the care plans or restraint agreements. In addition LO observed that the required consent of restraint agreements were lacking.
      • 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
      • R10.4N - 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): There is no system to ensure the physical facility is regularly monitored, ensuring compliance with the Residential Care Regulation.
      • 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): The program to instruct and if necessary assist persons in care to maintain their health and hygiene is ineffective. The facility is currently creating new care plans for the persons in care as this was a contravention from the February 23, 2021 inspection. At this time, new care plans have not been completed for all persons in care, so some care plans do not include descriptions or instructions for staff on how to provide and/or support specific care directives.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): LO reviewed oral health care plans for persons in care, however there was found to be inconsistent, missing, or lacking information. The facility is currently creating new care plans for the persons in care as Residential Care Regulation (RCR) 54(3)(b)(i) was a contravention from the February 23, 2021 inspection. At this time, new care plans have not been completed for all persons in care, so some care plans do not include updated oral health care plans.
      • R10.2I - Assist persons in care to maintain daily oral health; 54( 3 )(b)(i)
    • 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 the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan is ineffective. Inconsistencies were noted in regards to additional support required for scheduled daily personal care. The facility is currently creating new care plans for the persons in care as RCR 82 was a contravention from the February 23, 2021 inspection. At this time, new care plans have not been completed for all persons in care.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  10. Routine Inspection

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system that is in place to ensure reportable incidents are sent to the funding body immediately following the incident is ineffective. LO reviewed the incident log for reportable and non reportable incidents and noted that one incident had not yet been reported to the funding body as it was completed on an old form and faxed to Licensing. LO discussed the online portal reporting system with an employee, and she immediately logged onto the computer to access the portal to ensure she understood the process. The employee confirmed that the incident would be reported immediately following the inspection.
      • R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
      • R4.5E - Immediately notify the funding program, if any, if a person in care is involved in a reportable incident; 77( 2 )(d)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): 1)There is no system in place to ensure that there is an emergency plan in place to guide employees in the event of an emergency. The facility does not have an Emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures. 2) There is no system in place to ensure the site has a plan that sets out how persons in care will be cared for in the event of an emergency. The facility does not have a documented plan in place to guide employees in the caring for persons in care in the event of an emergency. 3) There is a system and a policy in place for bringing concerns forward and responding to them. The manager and employee stated they have had no concerns or complaints brought forward since the last Licensing inspection. They did state that they need to refresh themselves on the process as they were unable to locate the complaint binder at the time of the inspection.
      • R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
      • R2.1G - Have a plan that sets out how persons in care will continue to be cared for in the event of an emergency; 51( 1 )(b)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): 1) The system for ensuring persons in care's heights are recorded on admission is ineffective. Licensing Officer (LO) reviewed a persons in care's chart and noted that on admission their height was not recorded. The person's information sheet is located on the outer front of the chart, with the documented section for admission height not visible; therefore it was missed during the admission. The manager stated they will add admission height to another form or they will photocopy the backside of the sheet and place it in the front of the chart to prevent this from reoccurring. This was resolved as the person's height was taken and recorded during the inspection. 2) LO reviewed the system in place for record keeping for person's in care comfort funds, and ideas were discussed for an improved system. The manager stated she was currently exploring a different system to ensure accuracy and efficiency for the recording of person's comfort funds.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): UNRESOLVED from the April 2019 inspection. The system that is in place to ensure all employees comply with the Province's immunization program is ineffective. LO reviewed employee files and noted that two files were missing immunization screening.
      • R4.4C - Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
  11. Routine Inspection

    8 infractions

    • R6.1 - Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The process to ensure all employees have immunization screening completed in their files is infective. An employee's file was reviewed and it was found to be missing immunization screening.
      • R6.1A - Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The process in place for obtaining immunization history upon admission has been updated since the last inspection, however one individual's chart was not updated with the new process.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • RB1.9 - Are persons in care able to have family or a representative participate on the resident or family council on their own behalf?
      • Observation(s): There is currently no process in place for family/resident council meetings.
      • RB1.9A - Ensure persons in care are able to have family or a representative participate on the resident or family council on their behalf.
    • RB1.10 - Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
      • Observation(s): There is currently no process in place for family/resident council meetings.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The process in place for ensuring employees have a Criminal Record Check (CRC) from the Ministry is ineffective. In reviewing an employee's file a CRC from the RCMP was discovered. The manager stated that with the RCMP's CRC there is a section for screening individuals who are working with Vulnerable individuals, therefore she thought this was sufficient. The manager stated that she would talk with the employee and have them submit their application to the Ministry for a CRC by the end of the day. The manager has a process in place for obtaining character references for potential employees, however the answers to the questions asked are not kept in the employees file. The character reference form kept in the employee file contains the date, the name of the reference, and that they are a good hire. The manager stated that going forward she will keep all of the pages for the character reference together in the employee file.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The process for ensuring that the menu provides 2 nutritious snacks containing at least 2 food groups is ineffective. Licensing Officer reviewed the posted menu and there were no snacks listed on the menu.
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There is no system in place to ensure the Licensee offers the persons in care and their representatives the opportunity to come together at least once a year to meet and form a council. The Manager was unsure of when the last resident/family council meeting was held, and was unable to locate meeting minutes.
      • R10.2R - Provide at least an annual opportunity for persons in care and their parents or representatives, family members and contact persons to establish councils or similar organizations to represent the interests of persons in care; 59(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): There is no process in place to ensure that each person in care has an individualized oral care plan. Licensing Officer reviewed oral care plans and noted that there is no information listed to guide the employees in assisting persons in care with their oral hygiene. Behaviour care plans do not have behavioural interventions for all responsive behaviours listed to help guide the employees in providing care.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  12. Monitoring

    3 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): There is no system in place to ensure that the employees document on the person in care's medication administration record the effectiveness of the PRN medications that they administer to the persons in care.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): There is no system in place to ensure that persons in care who are admitted to the facility comply with the Province's immunization and tuberculosis programs. LO reviewed a person in care's chart who had been recently admitted to the facility, and the chart was missing TB and immunization screening. LO discussed this with the manager and she stated it was not completed during the admission to the facility.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system that is in place to ensure that persons in care's height and weight is documented on admission is ineffective. The system that is in place to ensure that persons in care's admission date is documented is ineffective. LO reviewed a person in care's chart who had recently been admitted to the facility and their admission date, weight, and height were not documented. LO discussed this with the manager and she stated it was not completed during the admission to the facility.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • R4.1D - Keep for each person a record showing the date of admission to the facility; 78( 1 )(b)
  13. Monitoring

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): October 20, 2017 - The facility does not have a system in place to maintain a record of the employee's character references. The manager stated that she calls the references provided by the employee, however there is no documentation or record on the employee's file. The facility does not currently have a system in place to ensure that performance of each employee is reviewed regularly.
      • R3.1C - Obtain character references for all employed persons; 37( 1 )(b)
      • 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)
  14. Monitoring

    4 infractions

    • 8.1 Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): August 18, 2015 - The facility currently does not have a process in place to ensure compliance with providing programming and supplies at the facility. The facility takes persons in care out to many activities outside of the facility, however there is currently no calendar available for pre-planned activities that take place in the facility. RCR 55 (3) (a)(b)Program of activities 3) A licensee must (a) provide, without charge, a sufficient quantity and variety of supplies, materials and equipment for the program of physical, social and recreational activities offered at the community care facility, and (b) ensure that supplies, materials and equipment are readily accessible and safe for use by the persons in care.
      • Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55( 1 )(a)(i)
    • 13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): August 18, 2015 - The facility currently does not have a process in place to ensure the compliance with providing programming and supplies at the facility. The facility takes persons in care out to many activities outside of the facility, however there is currently no calendar available for pre-planned activities that take place in the facility.
      • Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
    • 14 - Are sufficient materials, supplies and equipment for the program of activities readily accessible, safe, and provided without charge?
      • Observation(s): August 18, 2015 - The facility currently does not have a process in place to ensure the compliance with providing programming and supplies at the facility. The facility takes persons in care out to many activities outside of the facility, however there is currently no calendar available for pre-planned activities that take place in the facility.
      • Ensure supplies, materials and equipment are readily accessible and safe.
      • Ensure there is a sufficient quantity and variety of supplies. material and equipment for the program of activities.
    • 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): August 18, 2016 - UNRESOLVED - The facility's process for ensuring compliance with written policies for record keeping is ineffective. The current record keeping policy does not address the following regulations RCR 86, RCR 87, RCR 88, RCR 89, RCR 90, RCR 91, RCR 92.
      • Ensure there are written policies and procedures regarding the appropriate manner and schedule of record keeping; 85( 2 )(l)
  15. Monitoring

    13 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Feb 22, 2016 -UNRESOLVED - The falls policy does not address responding to a fall and the monitoring of a resident post fall. Feb 22, 2016- UNRESOLVED - Unable to locate a policy for monitoring residents and their medications.
      • Written falls prevention policies and procedures are required for assessing risks that may result in a person in care falling including a plan for preventing falls, responding to falls suffered and including care and subsequent prevention(Applies only to Long Term Care); 85( 2 )(a)(i)(ii)(iii).
      • Ensure there are written policies and procedures regarding monitoring of the medications of persons in care; 85( 2 )(h)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): Feb 22, 2016 - The facility is reassessing the restraints however there is no documentation on the restraint care plan of the reassessment.
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): Feb 22, 2016 - LO unable to locate a record of both in house incident reports and reportable incidents form 2015.
      • Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(a)
      • Retain a record of unexpected events involving persons in care; 88(b)
      • Retain a record of reportable incidents involving persons in care; 88(c)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Feb 22, 2016 - TB screens missing from two staff files that were reviewed.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Feb 22, 2016 - UNRESOLVED - Resident charts do not have complete immunization screening for pnemovax vaccine and tetanus and diphtheria. LO was unable to locate evidence of education that has been provided to residents and their representatives in relation to immunizations.
    • 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): Feb 22, 2016 - UNRESOLVED - Unable to locate the following policies: continuing education for managers and employees, a policy to guide family and residents on how to express concerns or bring complaints forward, monitoring of nutrition for residents, and a policy for record keeping, The orientation of new employees policy did not include orientation to the Residential Care Regulations and the Community Care and Assisted Living Act. Feb 22, 2016- LO unable to locate in house incident reports and IHA reportable incident reports for 2015. The employees are not following the facilities incident report policy.
      • Ensure policies are implemented by employees; 85( 1 )(d)
      • 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)
      • Ensure there are written policies and procedures for continuing education of managers and employees; 85( 2 )(c)
      • Ensure there are written policies and procedures for how persons in care, their parents or representatives and contact persons may express concerns, make complaints and resolve disputes under section 60; 85( 2 )(d)
      • Ensure there are written policies and procedures regarding monitoring nutrition of persons in care; 85( 2 )(g)
      • Ensure there are written policies and procedures regarding the appropriate manner and schedule of record keeping; 85( 2 )(l)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Feb 22, 2016 - UNRESOLVED - Unable to locate 2 or more character references, first aid certificate, food safe ,and work history in one employee file. UNRESOLVED - Two employee files were missing a TB Screen. Several staff files were missing a recent performance appraisal.
      • Obtain character references for all employed persons; 37( 1 )(b)
      • Obtain a record of work history for all employed persons; 37( 1 )(c)
      • 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 employees responsible for the preparation and delivery of food have the necessary experience, competence and training to ensure that food is safely prepared and handled, and meets the nutrition needs of persons in care; 44 ( 1 )(a)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Feb 22, 2016 - UNRESOLVED - The resident's immunization screening does not include pneumovax or Tetanus and diphtheria. Feb 22, 2016 - Unable to locate monthly weights in some residents charts.
      • 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
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): FEB 22, 2016 - UNRESOLVED - Staff files were missing character references, performance reviews and TB screens.
      • Keep employee character references; 86(b)
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Feb 22, 2016 - Unable to locate a policy to guide employees in the event of a facility outbreak or the prevention of an outbreak.
      • Develop general facility outbreak prevention and control policies as recommended by the medical health officer; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Feb 22, 2016 -Door frames, doors, lower walls, a resident's room, and bathroom in the lower area of the facility has heavy wall damage and requires patching and painting. -An electric outlet in a resident's room is missing a cover
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): Feb 22, 2016 - A resident's representative supplied vitamins to the facility for daily administration. The supplements were given to the resident without a doctors order.
      • Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
      • Administer only medications prescribed or ordered by the medical or nurse practitioner; 70 ( 1 )
    • 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): Feb 22, 2016 - Behaviour care plans for residents are vague and are not resident specific. The care plans do not outline behavioural triggers or interventions for the identified behaviours.
      • Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
  16. Monitoring

    8 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): August 11, 2015 -UNRESOLVED - The falls policy does not address responding to a fall and the monitoring of a resident post fall. August 11, 2015 - Unable to locate a policy for monitoring residents and their medications. RESOLVED - The facility now has an adequate policy for reportable incidents and restraints.
      • Written falls prevention policies and procedures are required for assessing risks that may result in a person in care falling including a plan for preventing falls, responding to falls suffered and including care and subsequent prevention(Applies only to Long Term Care); 85( 2 )(a)(i)(ii)(iii).
      • Ensure there are written policies and procedures regarding monitoring of the medications of persons in care; 85( 2 )(h)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): August 11, 2015 - UNRESOLVED - Resident charts do not have complete immunization screening. RESOLVED - Resident charts now contain TB screens.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
      • 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): August 11, 2015 - UNRESOLVED - The leather couch with rips and tears is now located in the downstairs lounge. The manager assured LO that it would be removed and taken to the dump by the end of the week.
      • Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(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): August 11, 2015 - UNRESOLVED - Unable to locate the following policies: continuing education for managers and employees, a policy to guide family and residents on how to express concerns or bring complaints forward, monitoring of nutrition for residents, and a policy for record keeping, The orientation of new employees policy did not include orientation to the Residential Care Regulations and the Community Care and Assisted Living Act. RESOLVED- The facility has made progress in developing policies and procedures to guide the staff. They now have an emergency plan, a policy and procedure for the release and access of residents, missing and wandering of a resident, and restraints. -The facility has developed a resident handbook that will be given to residents and their families who are newly admitted. In the handbook it provides information on fees and other payments for accommodation/and other services, how to bring concerns forward or make a complaint, and it provides the contact information for Licensing and PCQO.
      • 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)
      • Ensure there are written policies and procedures for continuing education of managers and employees; 85( 2 )(c)
      • Ensure there are written policies and procedures for how persons in care, their parents or representatives and contact persons may express concerns, make complaints and resolve disputes under section 60; 85( 2 )(d)
      • Ensure there are written policies and procedures regarding monitoring nutrition of persons in care; 85( 2 )(g)
      • Ensure there are written policies and procedures regarding the appropriate manner and schedule of record keeping; 85( 2 )(l)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): August 11, 2015 - UNRESOLVED - Unable to locate 2 or more character references and updated first aid certificates in some employee files, performance appraisals, and a food safe certificate in one employee file. -The manager submitted a Health and Safety Plan to address staff without current First Aide. There is currently 4 staff members with up dated First Aid. They will work or be present in the facility at all times until August 29, 2015 when the reaming staff complete their First Aid. RESOLVED- Criminal record checks, work history, certificates and diplomas, TB and immunization screening were found in employee files.
      • Obtain character references for all employed persons; 37( 1 )(b)
      • 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)
      • Ensure employees responsible for the preparation and delivery of food have the necessary experience, competence and training to ensure that food is safely prepared and handled, and meets the nutrition needs of persons in care; 44 ( 1 )(a)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): August 11, 2015 - UNRESOLVED - The resident's immunization status documented in their charts does not include pneumovax.
      • 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
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): August 11, 2015 -UNRESOLVED - The staff files were missing character references and performance reviews.
      • Keep employee character references; 86(b)
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): August 11, 2015 - UNRESOLVED - The fridges now have a thermometer and staff is monitoring the temperatures daily. However temperatures were documented out of the reference range of 0-4 degrees Celsius and there is no documentation indicating corrective measures were taken.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  17. Monitoring

    20 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): January 29, 2014 - UNRESOLVED - The policy for reportable incidents is inadequate as it is missing aggression between Residents and choking. The incident policy doe s not differentiate between reportable incidents to licensing and non reportable incidents. The policy does not guide the staff to complete in house incident reports nor does it identify who to report them to.
      • Ensure there are written policies and procedures regarding the use of restraints in an emergency; 85(2) (i)
      • Ensure there are written policies and procedures regarding responding to reportable incidents; 85(2) (j)
    • 4.3 Is documentation concerning restraints adequate?
      • Record the reason for the use of restraint in the person's care plan; 84(b)
      • Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 (1)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): March 23, 2015 - Inadequate Resident immunization screening, and education re: immunization to resident's and their families.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 (1)
      • 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
      • Provide information to persons in care regarding the benefits of immunization including pneumococcal, annual influenza and tetanus-diphtheria if appropriate; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
      • Consult with the medical health officer with respect to vaccine programs which should be offered to persons 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): March 23, 2015 - The leather couch and chair in the main sitting area has rips and tears visible.
      • Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
      • Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): March 23, 2015 - Resident's restraints were reassessed in February 2015. However the care plan does not indicate the frequently of reassessment.
      • Ensure all alternatives to the use of a restraint have been considered and either implemented or rejected; 73(2)(a)
      • Train employees in alternatives to the use of restraints. They must be able to determine when alternatives are most appropriate, when to use restraints and how to monitor the use of them; 73(2)(b)(i)
      • 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)
      • Provide in the care plan a plan to address, if there is agreement to the use of restraints, the type or nature of restraint and the frequency of reassessment; 81(3)(a)(iii)
    • 1 - Are all policies and procedures available to persons in care?
      • Ensure all policies and procedures are available to persons in care.
    • 5 - Are persons in care informed on how to express concerns or make complaints to the medical health officer or to the Patient Care Quality Office prior to admission?
      • Observation(s): There is no written information provided to families upon admission.
    • 6 - Are persons in care informed of all charges, fees and other amounts that must be paid for accommodation and other services prior to admission?
      • Observation(s): There is no written information provided to families upon admission.
    • 7 - Are persons in care able to have family or a representative receive advice prior to admission and, make complaints?
      • Observation(s): There is no written information provided to families upon admission.
    • 16 - Are persons in care who make prepayments provided written terms and conditions under which a refund may be made?
      • Observation(s): There is no written information provided to families upon admission.
    • 20 - Are rights of adult persons in care made known orally and in writing to the persons in care and their family and representatives?
      • Observation(s): There is no written information provided to families upon admission.
    • 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): January 29, 2014 - UNRESOLVED - The facility does not have adequate policies in place to guide the staff as required in the Residential Care Regulation. March 23, 2015 -The emergency plan does not include contact names, and phone numbers, -There is no policy and procedure in place for responding to emergencies other than a fire. -The policy and procedure for the fire does not address accommodation, food supply, staffing plan for 9 Residents should they be unable to return to the facility.
      • Advise of all charges/fees/other payments for accommodation/other services offered prior to admission; 48(1)(a)
      • Prior to admission, advise of policies respecting: expressing concerns, making complaints, and resolving disputes; 48(1)(b)
      • Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48(1)(c)(i)
      • 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)
      • Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51(1)(a)
      • Have a plan that sets out how persons in care will continue to be cared for in the event of an emergency; 51(1)(b)
      • Update emergency plans if there is any change in the facility; 51 (2)
      • Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(a)
      • 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)
      • Ensure there are written policies and procedures regarding access to persons in care by persons who are not employees of the community care facility; 85(2)(e)
      • Ensure there are written policies and procedures regarding the release of children, youths and vulnerable adults by authorized persons, including if an authorized person appears to be incapable of providing safe care to the person in care; 85(2)(f)(i)
      • Ensure there are written policies and procedures regarding responding to requests for release of children/youths/vulnerable adults by persons not authorized to do so; 85(2)(f)(ii)
      • Ensure there are written policies and procedures regarding monitoring nutrition of persons in care; 85(2)(g)
      • Ensure there are written policies and procedures regarding steps to be taken if a person in care leaves, or may have left, the facility without notifying an employee; 85(2)(k)
      • Ensure there are written policies and procedures regarding the appropriate manner and schedule of record keeping; 85(2)(l)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): March 23, 2015 - LO was given three staff files to inspect. Two of the files were missing character references. These references were submitted to LO the next day. -Unable to locate two staff files for the staff who were working during the inspection.
      • Ensure criminal record checks are obtained for all employed persons; 37(1)(a)
      • 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 employed persons are of good character; 37(2)(a), Act 7(1)(a)
      • Ensure that employed persons have the training and experience and demonstrate the skills to carry out duties assigned to the manager or employee; 37(2)(c)
      • Ensure that persons over 12 years of age that are ordinarily present are of good character and have a criminal record check (Applies only to Child and Youth Residential); 38
      • 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 employees have the necessary training and experience or demonstrate the necessary competence to carry out duties; 40 (3)
      • 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)
      • Ensure employees responsible for the preparation and delivery of food have the necessary experience, competence and training to ensure that food is safely prepared and handled, and meets the nutrition needs of persons in care; 44 (1)(a)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): June 18, 2014 - UNRESOLVED - The resident's immunization screening does not include pneumovax.
      • 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
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): March 23, 2015 See comments in the staffing section.
      • Keep employee criminal record check results; 86(a)
      • Keep employee character references; 86(b)
      • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
      • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
    • 4.6 Are facility records current and complete?
      • Observation(s): March 23, 2015 - The facility notified all families by sending out a letter of a family council meeting in October 2014 . There is a copy of the letter that was sent out to families and an agenda. However there is no record of who attended or nor is there meeting minutes recorded. -The facility currently does not have a resident council in place.
      • Retain records of compliance with family and resident council required in section 59; 89(2)(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): March 23, 2015 - There was food found in the refrigerator that was not dated. - RESOLVED - during the inspection a staff member discarded the food. The refrigerator did not contain a thermometer. The staff have been using the refrigerator setting as the thermometer. Therefore the fridge has not been properly monitored for safe temperatures of between 0-4 degrees Celsius.
      • Ensure that food is safely prepared, stored, served and handled; 63 (1)
      • Develop general facility outbreak prevention and control policies as recommended by the medical health officer; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): March 23, 2015 - A staff member who lives on site has an unlocked drawer in a bathroom that at times may be used by a Resident. Medications were located in the unlocked drawer.
      • Ensure all medications are safely and securely stored; 69(3)(a)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): March 23, 2015- There is currently no Resident Council in place.
      • Provide at least an annual opportunity for councils, or if no council is established, as a group, to meet with the licensee to promote the collective and individual interests of the persons in care and involve the persons in care in decision making on matters that affect their day to day living; 59(b)(i)(ii) (Show More)