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Cardinal House

A & B-4212 28 Ave Vernon BC V1T 1X6 · Residential Care - Licensing

Official record from Interior Health →

Inspection summary

Cardinal House has been inspected 11 times by Interior Health Authority since January 20, 2015. The most recent inspection, on May 13, 2026, recorded 5 infractions.

None of the 11 inspections on record were free of infractions. In the past 12 months there was 1 inspection with 5 infractions recorded. All recorded findings relate to upkeep, equipment or paperwork rather than direct health risks.

The number of infractions per inspection has stayed roughly the same over time.

What these findings mean

Health authorities word their findings differently, so we group them by what they mean for the people in care. Higher-risk findings are the ones that could directly make someone sick, and they matter more here because young children, older adults and people who are unwell are more vulnerable to infection.

  • Permits, records and postingLower risk

    Operating permits, required signage, written procedures and logs. These findings are administrative: the documentation was missing or out of date at the time of inspection.

    Recorded 16 times across 9 separate inspections, most recently on May 13, 2026. For example: 2 - Are written policies and procedures in place to guide staff in fall prevention?

  • Equipment and utensilsLower risk

    Equipment has to be made of cleanable materials, kept in good repair and stored properly. These findings are mostly about upkeep, like a cracked surface or worn part. They are generally lower risk but show how well the place is maintained.

    Recorded 4 times across 4 separate inspections, most recently on October 4, 2023. For example: 1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?

  • Other findingsLower risk

    Findings that do not fit the categories above, such as follow-ups that confirm an earlier violation was corrected, or requirements specific to this type of facility.

    Recorded 19 times across 9 separate inspections, most recently on May 13, 2026. For example: 3 - Is documentation concerning restraints adequate?

About this data

These results come from Interior Health Authority, which inspects food premises and other public facilities in this area. We republish the authority's public disclosure data and refresh it regularly; the official record is the final word.

11 inspections

  1. Routine Inspection

    5 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): A review of Care plans which identified the use of a Buckle Boss restraint, did not have any evidence of a Restraint agreement. Failure to have restraint agreements may compromise the health, safety and dignity of persons in care. Submit by May 28, 2026, the plan that will be implemented to come into compliance with Section 74(1)(b) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): During a review of a care plan which identified the use of a Buckle Boss restraint, there was no evidence of a monitoring system in place. The use of a restraint without monitoring increases the risk to the person in care's physical safety and emotional dignity. Submit by May 28, 2026, the plan that will be implemented to come into compliance with Section 84(d) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The system to ensure that all policies and procedures are followed is ineffective. A review of the First Aid checklists ensuring that first aids bags had all the necessary supplies was last completed in December 2025. Incomplete checklists may indicate that processes and checks were not completed on a monthly basis as per policy. Submit by May 28, 2026, the plan that will be implemented to come into compliance with Section 85(d) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • 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 system to ensure that employees are trained in the implementation of Emergency plans is ineffective. The Emergency drill program checklist identified drills that were not signed as been completed for January, September, October and December 2025. Employees not familiar with emergency drills increases the potential risk to the health and safety of persons in care during an emergency. This was also a contravention on the previous inspection. Submit by May 28, 2026, the plan that will be implemented to come into compliance with Section 51(3) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R3.1Z - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The system to ensure that the supervising pharmacist inspects and audits the area of the facility where medications are stored is ineffective. The Supervising pharmacist last inspected the site on May 10, 2025, with no pending scheduled inspection. The absence of regular pharmacist inspections could compromise the overall medication management system, potentially reducing the standard of care. This was also a contravention during a Routine Inspection in 2024. Submit by May 28, 2026, the plan that will be implemented to come into compliance with Section 68(2)(b) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(b)
  2. 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): The system to ensure the Emergency plan is updated is ineffective. A review of the Emergency plan in the Health & Safety Proofs binder identified an emergency contact which had not been updated. The same Emergency contact information was also noted to have not been updated in the Medication Administration Record binder and in the Individual Personal binders of the the persons in care. It is essential in time of an emergency that information is up to date otherwise this possesses a potential health and safety risk to persons in care during an emergency. Submit by May 16, 2025, the plan that will be implemented to ensure ongoing compliance with Section 51(2) of the Residential Care Regulation.
      • R2.1H - Update emergency plans if there is any change in the facility; 51 ( 2 )
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system to ensure that employees are trained in the implementation of Emergency plans is ineffective. The last documented emergency drill was from October 2024. It was also observed that the Emergency Drill Program Checklist was last completed in 2023. There was no evidence of a completed checklist for 2024. Employees not familiar with emergency drills increases the potential risk to the health and safety of persons in care during an emergency. Submit by May 16, 2025, the plan that will be implemented to ensure ongoing compliance with Section 51(3) of the Residential Care Regulation. The system to ensure employees are following policies and procedures is ineffective. During a review of the facility medication checklist, it was observed that on several occasions the cosigner had not signed for medication administered. The cosigner not complying with the policies and procedures of the medication safety and advisory committee and acknowledging whether the correct medication and time of medications administered is a potential safety risk to persons in care. Submit by May 16, 2025, the plan that will be implemented to ensure ongoing compliance with Section 68(4) of the Residential Care Regulation.
      • R3.1Z - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
      • R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system to ensure that each person in cares records contain all the required components is ineffective. During a random check of person in cares records, there was no evidence of Immunization status. All persons admitted to a community care facility are required to comply with the province’s immunization and tuberculosis control programs. The Licensee should ensure that records for person in care contain the immunization status. Not knowing the immunization status may pose potential health risks to the person in care and others within the home. Submit by May 16, 2025, the plan that will be implemented to ensure ongoing compliance with Section 78(1) of the Residential Care Regulation.
      • R4.1F - 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
  3. Routine Inspection

    2 infractions

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system to ensure all employees comply with the policies and procedures of the Medication Safety and Advisory Committee is ineffective. A review of the Medication Administration Records (MAR) identified a PRN medication that was signed off on two separate MAR’s for the same administration. As well as one of the signatures was not of the employee that had administered the medication.
      • R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The system to ensure that the supervising pharmacist inspects and audits the area of the facility where medication is stored is ineffective. The Supervising pharmacist last inspected the site in December 2022.
      • R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(b)
  4. Routine Inspection

    6 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system to ensure immediate notification to Licensing is ineffective as a review of critical incidents in a review of Care plans identified several reportable incidents which were not reported to licensing.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): During the inspection, several items addressed indicate an ineffective system for self-monitoring. For example, a binder containing the Fire alarm Inspection & Certification Report was not up to date, as were several other documents within the binder.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): The system to ensure an Emergency plan sets out how to continue care for persons in care is ineffective. Facility manager was not aware of the emergency preparations beyond evacuating to a muster point.
      • 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)
    • R4.6 - Are facility records current and complete?
      • Observation(s): The system to review and ensure records are current is ineffective. A review of the Medication safety and advisory committee (MSAC) policy located in the Medication Administration Record (MAR) binder containing the pharmacy contact information and members of the MASC committee was out of date. There was an updated version located on Sharevision which had not being transferred to the MAR binder.
      • R4.6L - Ensure all records are current; 91( 1 )(a)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system to ensure fridge and freezer temperatures are recorded is ineffective as evident by missed recordings on several fridges.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system to inspect and maintain emergency equipment is ineffective as evident by Fire extinguishers and Emergency lighting past due their inspection dates.
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
  5. Routine Inspection

    3 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Licensing reviewed person in care's records. There is no system in place to ensure all persons in care admitted comply with the Province's immunization and tuberculosis control programs.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): On inspection of the physical space, Licensing observed a bottle containing alcohol accessible to persons in care. The item was removed and placed in locked storage during the inspection.
      • 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): Licensing reviewed care plans for persons in care. Multiple had not been reviewed or revised in more than a year. Although the care plans were completed by outside agencies, Licensing recommended the manager review each care plan, revise if applicable and document when completed if agencies are not able to complete this at least once per year.
      • 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)
  6. Routine Inspection

    5 infractions

    • 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 noted the effectiveness of PRN's is not documented.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R4.6 - Are facility records current and complete?
      • Observation(s): Licensing reviewed facility records. Records for one person in care have not been kept current. The last records are from 2019 as this individual has been living independently from the program in a separated suite. This suite is a licensed space therefore, all person in care records should be kept current and complete.
      • 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 reviewed menu planning and observed the some meals to not be specific or contain 3 food groups and some snacks not to contain 2 food groups.
      • R5.1C - Provide for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups described in Canada's Food Guide; 62( 2 )(a)
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing observed a freezer storing a person in care's food as not monitored for temperature. There is a system in place for temperature monitoring in all other refrigerators and freezers. This is a re-occurring contravention from June 2019.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 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): As in R4.6: Care plans for one person in care have not been monitored on a regular basis to ensure proper implementation. Care plans for one person in care have not been reviewed or revised since 2019. One person in care self administers medication and a care plan to address this has not been developed.
      • R10.3B - Care plans must include a plan to address medication, including self-medication; 81( 3 )(a)(i)
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
      • 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)
  7. Routine Inspection

    1 infraction

    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): During inspection, it was noted that there is a process to monitor fridge temperature, but there was no system in place to monitor freezer temperature.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  8. Monitoring

    1 infraction

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The Manager reported structural changes had been made to one of the bedrooms on the main level. The manager was not aware that any structural changes had to be submitted to Licensing for approval prior to any changes being made.
      • R1.1B - Submit plans for the change to licensing and receive written approval prior to making any structural changes; 8( 2 )(a)(i)
      • R1.1D - Receive written approval from licensing prior to making any structural changes; 8( 2 )(b)
  9. Monitoring

    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): The system for ensuring compliance with reviewing policies and procedures at least annually is ineffective. In discussion with the manager, the policy manuals are not being reviewed annually. There is a process for the implementation of new policies but there is no process in place for reviewing the policies on an annual basis. In moving forward, a proposed process was discussed at the time of the inspection involving assigned staff to review specific policies.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
  10. Monitoring

    6 infractions

    • 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): As noted previously in the inspection report - the facility does not provide an annual opportunity for persons inc care and family members to establish and participate in a council to represent their interests.
    • 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): There are no minutes on file from the Medication Safety and Advisory Committee. The facility policy indicates that meetings are to take place twice a year.
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Several staff records had only one reference check. There were older staff records on file that did not contain any reference checks.
      • Obtain character references for all employed persons; 37( 1 )(b)
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Snacks are provided on the menu plan but do not contain at least 2 food groups described in the Canada's 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 )(b)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The bathroom fan in the basement level occupied by persons in care is very noisy and loud. The fan automatically comes on when the light is turned on.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There is no annual opportunity provided by the facility 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.
      • 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)
  11. Monitoring

    6 infractions

    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Holes noted to the couch in the large living area. Dining room chairs noted to be stained and damage to one of the dining chairs was covered with tape.
      • Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Policy on incident reporting did not include aggression between persons in care.
      • 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): Performance evaluations have not been completed since 2013. Facility policy indicates that performance reviews are to be completed annually. This infraction was noted on the last inspection report and remains outstanding.
      • 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)
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Menu plan did not include snacks.
      • 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)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Policies on outbreak prevention and control measures were not available.
      • 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): Damage noted to the flooring in several areas of the main living floor space.
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)

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