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Warner House

3665 Warner Ave Armstrong BC V0E 1B2 · Residential Care - Licensing

10 inspections

  1. Routine Inspection

    2 infractions

    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Daily notes binders for all persons in care (PIC) located on a counter that is accessible to PIC. During inspection, the manager moved Daily notes binders to a locked drawer. When persons in care confidential information is accessible to others, there is risk of detrimental impacts to their dignity and emotional health. Submit compliance plan by July 24, 2026, indicating how the licensee will ensure records and personal information of persons in care are kept confidential.
      • R4.1V - 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
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): While reviewing the menu, noted two days with one of the two snacks offered containing only one food group. When persons in care are not offered nutritious snacks, there is potential for negative health outcomes. Submit compliance plan by July 24, 2026, indicating how the licensee will ensure that each snack offered contains at least 2 food groups as described in Canada’s Food Guide.
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
  2. Routine Inspection

    1 infraction

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): It was observed that the menu substitution list had items that were not from the same food group, and did not meet the nutritional requirements of Section 62(2) and 62(3). The example provided was macaroni and cheese substituted by hot dogs. Not meeting the nutritional requirements and not following the Canada Food Guide impacts nutritional health outcomes of persons in care. Submit by May 23, 2025 evidence that the legislation regarding meal substitutions is being complied with and that any substitutions made are appropriate for the nutritional needs of persons in care.
      • R5.1I - Provide substitutions from the same food group and have a similar nutritional value; 62( 2 )(d)
      • R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
  3. Routine Inspection

    1 infraction

    • 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 review of PIC daily log notes indicated that required fields (re safety checks) were not being regularly completed.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  4. Substantiated complaint

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Staff did not notify the medical practitioner, Licensing and the funding program that the Person in Care was involved in a reportable incident.
      • R4.5C - Immediately notify the medical or nurse practitioner responsible for the person in care involved in a reportable incident; 77( 2 )(b)
      • 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): Staff did not follow facility documentation and incident reporting policies.
      • 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): Staff did not demonstrate the competence to carry out the duties regarding the care of a Person in Care.
      • R3.1L - Ensure employees have the necessary training and experience or demonstrate the necessary competence to carry out duties; 40 ( 3 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Licensing investigation determined that a staff person hit a person in care causing an injury.
      • R10.2D - Ensure persons in care are not subjected to financial, emotional, physical, sexual abuse or neglect; 52( 1 )(a)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Staff did not follow the terms and conditions of person in care's care plan.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  5. Routine Inspection

    1 infraction

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Licensing reviewed medication administration records and note PRN effectiveness to not always be documented.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
  6. Routine Inspection

    2 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): During inspection it was noted that staff signatures were missing for 6 entire shifts on the cleaning schedule task list.
      • 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): During inspection it was noted that the deep freeze in the basement was consistently recorded at being above facility requirements as documented on facility tracking form. There was no information on the temperature log to guide staff if temperature was out of range.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  7. Monitoring

    6 infractions

    • 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 evidence of continued compliance with the Provinces immunization and tuberculosis control programs. It was noted during the inspection that there was no immunization or tuberculosis screening completed for a new admission. It was noted during the inspection that immunization records for the flu were missing from the person in care records. This remains outstanding from the previous inspection reports.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
      • R6.2B - 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
    • RB1.19 - Are rights of adult persons in care displayed in a form and in the manner acceptable to the minister?
      • Observation(s): As previously mentioned in the inspection report: There is no system in place to ensure the adult bill of rights are displayed in a prominent place in the facility. The facility had their own bill of rights displayed but no adult bill of rights displayed.
      • RB1.19A - Display the rights of adult persons in care in a form and manner acceptable to the minister.
    • RB1.21 - Are rights of persons in care prominently displayed in the facility?
      • Observation(s): As previously mentioned in the inspection report: There is no system in place to ensure the adult bill of rights are displayed in a prominent place in the facility. The facility had their own bill of rights displayed but no adult bill of rights displayed.
      • RB1.21A - Display prominently the rights of persons in care.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): There is no system in place to ensure the adult bill of rights are displayed in a prominent place in the facility. The facility had their own bill of rights displayed but no adult bill of rights displayed.
      • R1.1Y - Display the rights of adult persons in care in a prominent place and in a form acceptable to the minister; Act 7( 1 )(c.1)(i)(ii)
    • 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): There is no system in place to ensure the emergency plans are updated with any change in the facility. It was noted during the inspection the lower level evacuation floor plan had not been updated with the change in the office relocation.
      • R2.1H - Update emergency plans if there is any change in the facility; 51 ( 2 )
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): There is no system in place to ensure all documents are on record. It was noted during the inspection that a photograph of a person in care was missing from one of the records of a person in care. It was noted during the inspection that consent to call a medical or nurse practitioner or ambulance was missing from one of the records of a person in care.
      • R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
      • R4.1I - 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)
  8. Monitoring

    2 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The process for monitoring records for immunizations is ineffective. Two person in care records were missing immunization records. Flu vaccines were completed at the facility this past October, but there are no records indicating that the flu vaccine was given or refused in the person in care records. Immunization screening records remains outstanding from the previous inspection report.
      • R6.2B - 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
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It was noted during the inspection that one bedroom did not have any window coverings. A discussion took place with the manager in regards to privacy of the person in care. Due to specific care routines, it was determined that privacy was not a concern at this point in time, but the type of coverings could be a safety concern. Therefore the manager was given a specific timeline to further discuss and acquire the correct window coverings suitable to meet the health, safety and dignity of the person in care.
      • R7.1W- Each bedroom must have a window that provides natural light, with coverings to block light and protect privacy; 28 ( 1 )
  9. Monitoring

    4 infractions

    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Immunization records were noted to be missing on one person in care.
      • 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
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Written consents to call medical or nurse practitioner or ambulance noted to be missing from person in care records. Monthly weights noted to be missing for two months in the records of a person in care.
      • 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)
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Several stained areas noted on the outside deck.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
    • 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): Oral care plan on one person in care has not been reviewed since April of 2014. This item remains outstanding from the last inspection
      • 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)
  10. Monitoring

    15 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Written consents not obtained from the medical practitioner or representative for a restraint being used on a person in care.
      • Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73(2); 75(2)(a)(i)(ii)(b)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): There was not any supporting documentation in regards to the reason of a restraint, record of alternatives, record of the duration and record of assessments for a restraint being used.
      • 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 duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
      • Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • 8.1 Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Activity calendar inadequate in providing ongoing planned program of physical, social and recreational activities offered in house.
      • 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)
    • 8.2 Does the program of activities support individualized care plan requirements?
      • Observation(s): Activity program is incomplete in offering planned ongoing activities offered on site.
      • Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55(1)(a)(ii)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): Incomplete restraint care plan noted for a restraint being used by a person in care.
      • Ensure all alternatives to the use of a restraint have been considered and either implemented or rejected; 73(2)(a)
      • Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73(2)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)
      • 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)
    • 9 - Are persons in care able to have family or a representative participate on the resident or family council on their own behalf?
    • 13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Reportable incident policy did not include aggression between persons in care. (Schedule D)
      • Review and, if necessary, revise policies and procedures at least once a year; 85(1)(b)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Staff information sheet provided by the manager. It was noted on the information sheet that a few of the staff had past due performance evaluations.
      • 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)
    • 4.6 Are facility records current and complete?
      • Observation(s): Unable to locate a policy on the Medication Safety Advisory Committee in regards to what the committee is responsible for and how often the committee meets.
      • Keep a copy of each policy and procedure of the medication safety and advisory committee; 85 (15)
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Menu plan did not always include 2 nutritious snacks with each snack containing 2 food groups from the Canada Food Guide.
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62(2)( c)(i)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Cleaning supply closet found to be unlocked and cleaning supplies accessible to persons in care. There was also dish washing detergent pucks found in the cupboard underneath the kitchen sink hazardous to persons in care. All hazardous materials require safe and secure storage. Laundry room door was locked by the manager during the inspection as staff members are responsible for doing the laundry. (CDI) Equipment test sheets indicated that equipment is to be checked semi annually and there are only reports to indicate that this is being done once a year. Manager stated that there was a fire inspection completed last year but a copy of the inspection was not on record. Fire extinguishers had been checked last year. Prescription treatment creams were found on the counter in the persons in care bathroom. The manager removed the creams and securely stored them during the inspection. (CDI)
      • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signaling devices; 22 (15)
      • 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)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): There is no evidence on site to support that a Medical Safety and Advisory Committee has been established or that the supervising pharmacist has come on site to inspect the medication storage area.
      • Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68(1)(a)(b)(c) (Show More)
      • Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68(2)(a)(b)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There is no evidence that there are resident or family council meetings taking place.
      • 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)
      • 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)
    • 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): Oral care plan on a person in care has not been reviewed since 2010.
      • 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)