White Heather Manor

3728 Casorso Rd Kelowna BC V1W 4M8 · Residential Care - Licensing

11 inspections

1. Routine InspectionSep 23, 2026

   3 infractions

   • R7.2 - Is the environment maintained to prevent falls?
     • Observation(s): A physical inspection of the facility and furniture identifies that several pieces of furniture are in extremely poor condition, with chairs noted to have torn armrests and damaged seats. Additionally, exercise equipment is noted to be dirty and dusty. When furniture and equipment are not kept in clean and safe condition, the risk of infection transmission may increase. Additionally, the dignity of persons in care may be affected. Submit to Licensing by October 13, 2026, a plan outlining how all furniture and equipment will be maintained in a safe and clean condition. 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.
     • R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
   • R4.6 - Are facility records current and complete?
     • Observation(s): A review of the records of complaints indicates that responses to complaints are not consistently documented as required by legislative requirements. When a complaint is not responded to, it may increase the risk of concerns being left open and create gaps in documentation, which may make it difficult to determine whether the concern was investigated and resolved. Submit to Licensing by October 12, 2026, a plan outlining how all records of complaints will include the responses to them 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. A review of the emergency plan identifies that some room numbers do not correspond with the persons in care currently residing in those rooms. When emergency records are not kept current and accurate, there is an increased risk that persons in care may not be appropriately assisted during an emergency. The Licensing Officer returned to the site on September 24, 2026, to further discuss and clarify this contravention. At that time, the emergency plan was updated to reflect the correct room assignments and names of persons in care. However, a plan is still required to address ongoing compliance. Submit to Licensing by October 13, 2026, a plan outlining how emergency plans will be maintained accurately and currently as per legislative requirements. The plan must identify the measures that will be implemented to ensure ongoing compliance.
     • R4.6F - Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
     • 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): An inspection of the physical facility identifies general cleanliness concerns, including: -Various ceiling vents observed to be dusty. -A window screen in one person in care room was noted to have moderate sized hole. -Light fixtures were observed to be dusty and dirty. -Walls throughout the facility were observed to be dirty and in need of cleaning. -Outside of building observed to be dirty. Maintaining the facility in a clean condition supports the health, safety, and dignity of persons in care. When cleaning concerns are not addressed, the risk of infection prevention and control issues may also increase. Submit to Licensing by October 13, 2026, a plan outlining how the facility will be maintained in a safe and clean condition. 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. A large, heavy umbrella stand is noted to be in the path of a designated exit as identified on the facility's emergency plan. When emergency exits and routes are not kept clear, the risk of injury or death may increase in the event an evacuation is required. Upon return to the site on September 24, 2026, it was observed that the umbrella stand had been relocated to the side of the path, significantly reducing the risk of obstructing the exit route. Submit to Licensing by October 13, 2026, a plan outlining how all emergency exits and routes will be kept clear at all times. 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)
     • R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
2. Routine InspectionMay 20, 2025

   4 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): Observed the medication cart with three bottles of vitamins with no labels. The Manager advised there was a prescription for the vitamins; however, the Licensee does not have a policy for applying labels if purchased outside of a pharmacy. Not having labels on medications may increase the risk to persons in care as medications may be administered incorrectly. A revised medication policy was submitted to Licensing on May 21, 2025, which addresses the need for medication labels if medication is purchased outside of the pharmacy. The Licensee also submitted a revised medication cart audit checklist which reflects the need to check for labels on all medication bottles. The information submitted included details on how employees would be made aware of the revised policy and procedure. No further action is required by the Licensee.
     • R2.1N - Establish and review policies and procedures on safe and effective storage, handling and administration of medications; 68( 3 )(b)(i)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): A review of employee files showed that one employee, who takes persons in care out to activities independently, had an expired first aid and cardiopulmonary resuscitation (CPR) certificate. Not having a valid first aid and CPR certificate may increase the risk to persons in care if medical attention is required and the employee does not have required certification to perform the necessary steps. The Licensee provided an immediate health and safety plan to ensure that all persons in care have access to an employee with a valid first aid and CPR certificate while in the community and in the care of the Licensee. Submit by June 09, 2025, a plan detailing how it will be ensured that all persons in care will have access to an employee who holds a valid first aid and CPR certificate. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
     • R3.1R - 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)
   • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
     • Observation(s): It was noted that some persons in care have refrigerators in their rooms; however, the Licensee does not have a system in place to monitor the temperature of these refrigerators or monitor rooms to ensure food is being safely stored and appropriate for the nutritional needs of persons in care. Lack of monitoring and oversight of food being stored in rooms may increase the risk to persons in care as persons in care may ingest food that is not safe due to being stored incorrectly. Submit by June 09, 2025, a plan detailing how rooms will be monitored to ensure any food is being safely stored. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
     • 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 a laundry room door was noted to be unlatched. Unlocked rooms which contain cleaning products may increase risk to persons in care as the cleaning products may be used incorrectly or ingested and cause adverse reactions. Submit by June 09, 2025, a plan detailing how rooms that contain cleaning products will be monitored to ensure they are locked. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
     • 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 InspectionJun 20, 2024

   2 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): The system in place to ensure overnight monitoring is completed as required by facility policy was found to be ineffective. During the inspection, overnight monitoring documents were reviewed and found to be missing information related to persons in care being asleep or awake. The facility policy indicates that each check must be documented by either A for awake or S for sleeping; however, the documentation reviewed contained blank spaces and lines. This was a contravention on the last complaint inspection, but captured under section R10 - Care and Supervision.
     • 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 renewable certifications and training requirements are current was found to be ineffective. During the inspection, it was noted that upon hiring a checklist is sent to the employee to ensure required information is submitted; however, there is no system for follow-up or continual monitoring after the initial request. The Licensee does not have a system in place to ensure that character references are obtained for all employed persons. During the inspection, two employee files were reviewed and both files contained only one character reference. This was despite the facility policy of requiring two character references.
     • R3.1C - Obtain character references for all employed persons; 37( 1 )(b)
     • R3.1I - 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)
4. Substantiated complaintJan 4, 2024

   6 infractions

   • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
     • Observation(s): Allegation-The Licensee is in non-compliance with Residential Care Regulation 42(1)(a)-Staffing coverage, as it pertains to no nurse being on duty for an evening shift in December 2023. Findings-SUBSTANTIATED. During the inspection, it was noted that there was no nurse on-site as indicated in the staffing plan. To help mitigate the risk the Licensee did put a contingency plan into place. The plan, which included an on-call nurse and delegation of task to a trained HCA for medication administration; however, as the HCA medication administration training program was not reviewed and approved by a MSAC, a contravention was noted as stated above in section R2.1M.
     • R3.2A - There must be sufficient numbers of trained and experienced employees on duty at all times. Staffing patterns must meet the needs of persons in care and assist persons in care with activities of daily living, including eating, mobility, dressing, grooming and hygiene in a manner consistent with the health, safety and dignity of persons in care; 42( 1 )(a)(b) (Show More)
   • R4.5 - Are incidents and notifications reported and records retained as required?
     • Observation(s): Allegation-The Licensee is in non-compliance with Residential Care Regulation 77(2)(d)-Reportable incidents, as it pertains to reportable incidents not being reported to the funding program as required. Findings-UNSUBSTANTIATED. During the inspection, it was observed that instructions for notifying the funder had been added to the fax machine as well as in the incident report binder. The Licensee addressed this concern prior to the inspection and Licensing Officer Hensel found no indication that the additional directions were not being followed. Contravention-RCR 77(2)(c). During the investigation, it was found that the Licensee did not notify Licensing as required after 4 persons in care tested positive for COVID within a 24 hour period.
     • 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): Contravention-RCR 68(3)(a). During the investigation, it was noted that a delegation of tasks was put into place regarding medication administration by Health Care Aides (HCA); however, it was identified that this training was not reviewed and approved by the Medication Safety Advisory Committee (MSAC), as required by the legislation. Contravention-RCR 85(1)(d). During the investigation, it was noted that the facility's policy for Respiratory and Gastrointestinal Outbreak Guidelines was not followed. The facility policy states, "Reference and apply Interior Health Authority's Gastrointestinal and Respiratory Outbreak Guidelines". The referenced guidelines state a facility's reporting threshold is 4 or more positive cases as determined by testing. Despite meeting the reporting threshold, the Licensee did not report this outbreak occurrence to the Communicable Disease (CD) unit as required in the guidelines.
     • R2.1M - Establish and review training and orientation programs for employees who store, handle or administer medications to persons in care; 68( 3 )(a)
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): Allegation-The Licensee is in non-compliance with Residential Care Regulation 16 (1)-Temperature and lighting, as it pertains to a thermostat in a person in care's room being broken. Findings-UNABLE TO SUBSTANTIATE. The concern brought forward did not contain sufficient information to enable Licensing to investigate. Contravention-RCR 22(3). During the on-site inspection, staff noted that a thermostat in a person in care's room had been inspected by maintenance to ensure it was in working order. LO Hensel requested maintenance documents that were related to any thermostat concerns; however, the Licensee reported they could not locate any maintenance records related to thermostats. Since this inspection, the Licensee has put additional education in place to ensure employees are trained in utilizing the maintenance documents that are in place.
     • R7.1A - Room temperatures must be safe and comfortable; 16 ( 1 )
     • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
   • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
     • Observation(s): Allegation- The Licensee is in non-compliance with Residential Care Regulation 50(1)-Continuing accommodation, as it pertains to a person in care being burned by a heater. Findings- UNABLE TO SUBSTANTIATE. The concern brought forward did not contain sufficient information to enable Licensing to investigate. Contravention- RCR 50(1) During the investigation, it was noted that there was insufficient/incomplete documentation to reflect that persons in care were being monitored overnight as required. A system is in place; however, the documentation contains blank spaces and lines instead of the S-sleeping and A-awake as indicated in the facility policy.
     • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
   • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): Contravention- RCR 81(3)(f)(i)(ii). During the investigation, it was discovered that a person in care was known to leave the facility without notifying an employee or following the sign out process. The care plan was reviewed and it was noted that it was lacking direction to help guide staff in locating the person in care should they leave the facility and not follow the facility's sign out process.
     • 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)
5. Routine InspectionMar 8, 2023

   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 it was noted that policies and procedures were outdated, most having expired in 2021. The interim manager has a plan to update the policies and procedures, however many remain outdated at this time. The Licensee's system for ensuring that the medication refrigerator temperatures are monitored is ineffective. During the inspection it was noted that eight out of 28 days were missing and not recorded. The Licensee's system for ensuring that employee files are complete is ineffective. During the inspection five employee files were reviewed and three of these files were found to not have a completed orientation checklist. The Licensee's system to ensure that all staff receive a performance evaluation within the three month probationary period is ineffective. During the inspection the manager confirmed that probationary evaluations are not occurring and that employees receive their first performance evaluation at the one year mark. This is in contrast to the facility policy which indicates that each employee must have one performance evaluation within the probationary period.
     • 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): The Licensee's system to ensure that monthly weights are consistently recorded is ineffective. During the inspection four person in cares charts were reviewed and it was noted that two of those charts were missing various monthly weight documentation.
     • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
   • R4.6 - Are facility records current and complete?
     • Observation(s): The Licensee's system to ensure that facility records are current and complete is inefficient. During the inspection it was noted that the emergency contacts list had not been updated since 2013.
     • 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): The Licensee's system to ensure that the menu meets the requirements of the legislation is inefficient. During the inspection it was noted that the menu did not include two snacks per day with two food groups.
     • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): During the inspection it was noted that one laundry room, where chemicals were present, was unlocked with no staff close by. The door was immediately locked once this was noticed.
     • R7.1AM - Ensure that laundry facilities if not used by persons in care, cannot be accessed by persons in care; 35( 2 )(b)
   • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): During the inspection it was observed that a person in care who consumed tobacco did not have a care plan in place to help guide care. Licensing was informed that there should be a smoking care plan in place.
     • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
6. Routine InspectionFeb 9, 2021

   3 infractions

   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): The Licensee did not notify Licensing of the Licensee's name change. During the routine inspection, the manager of the facility indicated that the parent company (Licensee) had changed their name. An amendment application was sent to Licensing during the inspection and will be processed by Licensing. This contravention will be considered resolved during the inspection.
     • R1.1A - Notify licensing immediately of changes to original application; 8 ( 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): The system in place to ensure that the facility has policies and procedures in place to guide employees is ineffective. A Health and Safety Plan was created on September 2, 2020 to ensure that the policies were in place to guide staff when submitting incident reports. Since the Health and Safety Plan was accepted by licensing, over half of the incident reports submitted to Licensing required follow-up for further information, indicating the policies are not being implemented by employees. In two instances, it was also found that the policy regarding reviewing and updating care plans after an incident was not followed.
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
   • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
     • Observation(s): The Licensee provided the Licensing Officer with 5 weeks worth of menus. The menus did not contain the daily snacks that were being provided.
     • 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)
7. Routine InspectionDec 12, 2019

   3 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 that all persons in care are screened for TB and immunization status upon admission to the facility. LO reviewed a person in care's chart who was recently admitted to the facility and noted that immunization and TB screening were missing from their chart. LO reviewed a person in care's chart who has resided at the facility for a number of years and it was missing TB screen and immunization screening. Upon discussion with the manager it was stated that the chart was likely thinned and the information was removed. LO explained it is the Licensee's responsibility to ensure that there is a system in place for the monitoring/auditing of persons in care's charts to ensure that compliance is maintained.
     • 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): 1) There is no system in place to advise persons and their representatives prior to admission of all charges, fees or other payments for accommodation and services offered. 2) There is no system in place to notify persons in care and their representatives prior to admission of how to bring concerns forward to Licensing or the Patient Care Quality and Review Board. 3) The system in place to ensure that the facility has policies and procedures in place to guide employees is ineffective. 4) There is no system in place to ensure that there is outbreak prevention and control policies in place to guide employees. LO requested to review the facility's influenza and outbreak policy; however there is not one in place. The manager began the process of implementing an influenza policy during the inspection. Licensing Officer discussed with the manager the new legislation in place for Health Care Consent that became effective on November 04, 2019. The organization recently updated all email addresses; however Licensing was not notified of these changes. This resulted in the Licensee and Manager not receiving the updated information for the changes in the Legislation effective November 04, 2019. Licensing Officer has since emailed all new legislation information to the Manager.
     • R2.1A - Advise of all charges/fees/other payments for accommodation/other services offered prior to admission; 48( 1 )(a)
     • 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)
     • R2.1D - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to the Patient Care Quality Review Board Act; 48( 1 )(c)(ii)
     • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
   • 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): 1) The system in place for ensuring that persons in care's care plans include behavioural interventions is ineffective. LO reviewed a care plan for a person in care who is noted to have responsive behaviours; however the plan did not include behavioural interventions. LO reviewed the behaviour care plan with the nurse who verbally provided behaviour interventions that are used for this person in care; however they were not recorded on the behaviour care plan. 2) The system in place to have care plans in place for individuals who are identified to be at risk for leaving the facility without providing notification to employees is ineffective. LO reviewed a care plan for an individual who was identified to be an elopement risk; however there was no plan in place to prevent them from leaving the facility.
     • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
     • 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)
8. MonitoringJun 22, 2018

   3 infractions

   • RB1.13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
     • Observation(s): Not all persons in care have a recreational care plan developed that identifies their recreational goals and needs.
     • RB1.13A - Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
   • RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
     • Observation(s): Not all persons in care have a recreational care plan in place that addresses their social and emotional needs, as well as their cultural and spiritual preferences.
     • RB1.23A - Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
   • 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 system in place to ensure all persons in care have a recreational care plan in place that takes into account and reflects each person in care's unique abilities, physical, social and emotional needs, as well as their cultural and spiritual preferences.
     • 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)
     • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
9. MonitoringNov 6, 2017

   3 infractions

   • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
     • Observation(s): November 06, 2017 - UNRESOLVED - There is no system in place to ensure that all persons in care comply with the Province's immunization and tuberculosis control programs. LO reviewed five persons in care's charts and all five charts did not contain immunization screening. One person in care's chart was missing a TB screen.
     • 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): November 06, 2017 - There is no system in place to ensure employees are implementing the facility's policies. LO reviewed progress notes for three persons in care who have suffered from a fall. The employees are not consistently documenting the nursing assessments conducted, and vitals signs that were taken at time of the fall as required by the facility's falls policy.
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
   • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): November 06, 2017 - UNRESOLVED - There is no system in place to ensure all persons in care have an oral care plan. Out of ten care plans reviewed one was noted to not contain an oral care plan. UNRESOLVED - There is no system in place to ensure that the persons in care's nutrition care plans are reviewed with a dietician on a regular basis. Five nutrition care plans were reviewed and all five had not been reviewed or revised in over a year. LO reviewed a person in care's dietary notes, and observed a dietician's nutrition assessment from Jan 2017. The assessment identified a significant change in the person in care's dietary status, and this change was not identified on their nutrition care plan. UNRESOLVED- There is no system in place for ensuring care plans are reviewed and revised on a regular basis, or at least once a year. Out of ten oral care plans reviewed it was noted that all ten have not been reviewed or revised in over a year.
     • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
     • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
     • R10.3P - Develop, with the assistance of a dietician, a nutrition care plan for each person in care and review the plan with a dietician on a regular basis (Applies to a facility with 24 or more persons in care); 83( 2 ), 83( 3 )(b)
10. MonitoringMar 9, 2017

    7 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): March 09, 2017 - UNRESOLVED -The facility does not have a system in place to ensure compliance with the screening of persons in care to verify their immunization status. LO reviewed persons in care's charts and was unable to locate immunization screening. LO discussed this with the manager and he stated there was currently no system in place to ensure immunization status for all persons in care. The facility does not have a system in place to ensure persons in care are educated in regards to the benefits of immunization.
      • 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
      • R6.2C - 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
    • RB1.13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): March 09, 2017 - The facility does not have a system in place to ensure compliance with having a designated employee with sufficient time away from other duties to carry out daily activities for persons in care. The employee who is currently running activities also works in other departments within the facility. The facility is not currently offering daily activities to the persons in care.
      • RB1.13A - Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
    • 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): March 09, 2017 - The facility does not have a system in place to ensure employees are following facility policies. LO inspected employee files and discovered that some files were missing criminal record checks, and up to date first aide certificates. Therefore the facility is not following their policy for first aid and criminal record checks. The facility does not have a system in place for ensuring compliance with reviewing and revising policies at least once a year. The manager stated that he was aware that some of the policies need to be reviewed, however in his new position he has not yet had a chance to create a formal system to ensure that this occurs yearly.
      • 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): March 09, 2017 - The facility does not have a process in place to ensure compliance with employee files containing up to date first aid certificates. The facility manager has submitted a Health and Safety Plant to Licensing that was accepted. The facility will ensure that there is an employee on at all times that has a current first aid certificate. The manager has registered the employees whose certificates have expired for a up coming first aid course. The facility does not have an employee in place that has sufficient time away from other duties to carry out daily social and recreational activities for persons in care. The employee who is currently running the activities department also works in other areas within the facility. The facility is not currently offering daily activities to the persons in care.
      • R3.1O - Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
      • R3.1T - Designate an employee, qualified by training or experience, to organize and supervise physical, social and recreational activities (Does not apply to Hospice); 45(a)
      • R3.1U - Give the designated employee sufficient time away from other duties to carry out the activities (Does not apply to Hospice); 45(b)
      • R3.1V - Provide sufficient time for persons in care to participate in activities (Does not apply to Hospice); 45(c)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): March 09, 2017 - The facility does not have a process in place to ensure compliance with all employee files containing criminal record checks. The manager stated that the previous owners had obtained the criminal record checks and kept them in their records rather ensuring they were stored in the employee files. The manager has been in contact with the ministry to obtain copies of criminal record checks for those employees whose files did not contain one.
      • R4.4A - Keep employee criminal record check results; 86(a)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): March 09, 2017 - The facility does not have a process in place to ensure a notice is displayed in a prominent location to notify persons in care and the public of electronic surveillance.
      • R7.1G - Display a notice in a prominent place if electronic surveillance is being used to transmit or record images of persons in care or members of the public; 19 ( 13 )
    • 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): March 09, 2017 - The facility does not have a system to ensure care plans are in place and updated to reflect behaviour interventions for persons in care. LO reviewed nursing notes that described a person in care's behaviour that required intervention by employees. LO then reviewed the behaviour care plan and there was no documentation present to guide the employees for intervention of the behaviours. The facility does not have a system in place to ensure oral care plans are updated yearly and located in each person in care's chart. The facility does not have a system in place to ensure that each person in care has an up to date nutrition assessment and nutrition care plan in place. A dietician has been working with the facility to develop and critique a new four week menu. The dietician has conducted nutrition assessments and nutrition care plans for the persons in care who are considered high risk, and will continue to assess care plans for the remaining persons in care.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
      • 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)
      • R10.3K - 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)
11. MonitoringJan 5, 2016

    7 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Jan 05, 2016 - Even though the regulation states "applies only to long term care" it is the facilities responsibility to have policies and procedures in place to guide the staff in meeting all resident's health and safety needs. -There is no policy for preventing falls or responding to falls. -LO unable to locate documentation on post falls assessments and fall prevention strategies put into place for a resident who has had several falls.
      • 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).
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): Jan 05, 2016 - LO discovered incidents of missing/wandering in the in-house incident binder. They were not reported to Licensing as a reportable incident.
      • Immediately notify the medical or nurse practitioner responsible for the person in care involved in a reportable incident; 77( 2 )(b)
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
      • Immediately notify the funding program, if any, if a person in care is involved in a reportable incident; 77( 2 )(d)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Jan 05, 2016 - LO unable to locate documentation for each resident in their chart on their immunization status. The Manager documented all immunization screening on the residents medical page by the second day of inspection.
      • 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
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): Jan 05, 2015 - Regulation states "long term Care only" however it is the facilities responsibility to assess and address each residents care needs and care plan accordingly. LO unable to find adequate fall prevention care planning for a resident who has had multiple falls.
      • Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (Show More)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Jan 5, 2016 - The last inspection was not posted. The inspection that was posted was from 2013. Two electric scooters were blocking the show case where the inspection report was posted. -The facility has a new license posted that does not contain the manager's name. -The facility manager's name is not posted in a prominent visible area.
      • Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
      • 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)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Jan 05, 2016 - LO unable to locate written consent from residents or a family member.
      • 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)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Jan 05, 2016 - LO unable to locate documentation in a resident's chart for post falls assessment, ROM, Vital signs, or neuro vitals following several falls. -Residents who leave the facility temporarily do not carry facility ID on them.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
      • Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56( 1 ) ( 2 )