Castleview Care Centre

2300 14 Ave Castlegar BC V1N 4A6 · Residential Care - Licensing

14 inspections

1. Routine InspectionJun 25, 2025

   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 to ensure that all staff implement policies is ineffective. The aggressive alert flagging process was not followed as two persons in care had aggressive alerts on their doors, and their charts, but not on their care plans in the care plan binder. Failure to follow the facility's aggressive alert policy may result in staff not noting the behavioral interventions in the care plan. Thus increasing risk to the health and safety for all persons in care. Submit by July 10, 2025, a written plan confirming that the two missing aggressive alerts have been added to the care plans in the care plan binder. The plan must also detail how you will ensure that alerts are in place for all person in care who require them. The plan must include the system you will implement to support ongoing monitoring to ensure sustained compliance.
     • 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): There was no record of emergency drills for the months of January, February, March or April. There was a record of a drill completed in May, and plans for a drill to be done in June. When fire drills are not routinely conducted it increases risk to persons in care's heath and safety, as staff maybe unaware of how to respond in an emergency Submit by July 10, 2025, a written plan outlining how you will ensure that all staff will be trained in emergency plans. The plan must detail how you will ensure that emergency drills will be completed regularly and include the system you will implement to support ongoing monitoring to ensure sustained compliance. Employees were not following the facility's policy and procedure for the documentation of as needed (PRN) medication effectiveness. At least five persons in care had received a PRN medication within the past two weeks without having the effectiveness being recorded. Lack of documented effectiveness of PRN medications increases the risk to persons in care as they may not receive their as needed medication in manner that meets their needs. Submit by July 10, 2025, a plan outlining how you will ensure that the effectiveness of PRN medications will be documented. The plan must include the system for ongoing monitoring to ensure sustained compliance.
     • 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 )
2. Routine InspectionMay 23, 2024

   2 infractions

   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): The system for ensuring required information is recorded on admission appeared to be ineffective. Upon a random review of residents' records, licensing officer noted that height and weight were not recorded on admission in multiple charts.
     • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
   • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): The system for ensuring care plans are reviewed/revised annually or when there is a change in status to a person in care appeared to be ineffective. Upon a random review of care plans, licensing officer noted one care plan reflecting the use of restraints, however, the person in care was not utilizing the restraint. The licensee has rolled out a new process for Activities of Daily Living (ADL) care plans. Upon a random review of the ADL care plans, the licensing officer was unable to ascertain when the plans were last reviewed as most were not dated. This is an outstanding contravention from the previous inspection which was initially noted to be out of compliance on March 8, 2023.
     • 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)
3. Substantiated complaintMar 21, 2024

   1 infraction

   • R4.5 - Are incidents and notifications reported and records retained as required?
     • Observation(s): The allegation pertains to reportable incidents, and that a person in care's representative was not immediately notified of their involvement in a reportable incident. During the Licensing investigation the reportable incident report, the timeline of events, and the system in place for immediately notifying representatives of reportable incidents was reviewed. The finding is this complaint is SUBSTANTIATED.
     • R4.5B - Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77( 2 )(a)
4. Substantiated complaintMay 9, 2023

   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 complainant alleged that the facility was not staffed to meet the person in cares' needs. From the dates provided, licensing was able to confirm that the licensee had enacted their contingency staffing plan. Licensing attended the facility to review records and policies and speak with staff and management. From the information gathered, licensing was able to confirm that a portion of the policy had not been followed and therefore licensing finds this complaint to be Substantiated.
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
   • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
     • Observation(s): The complainant expressed concerns with wound care. Licensing reviewed the wound care process and noted the wound care treatment plans were not clear. The direction as to what to do, and how often to do it was inconsistent. Licensing finds this complaint to be Substantiated.
     • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
5. Routine InspectionMar 8, 2023

   3 infractions

   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): The system for ensuring the documentation of the effectiveness of PRN medications appeared to be ineffective. Licensing reviewed medication administration records for February and March and noted inconsistencies with PRN effectiveness documentation.
     • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
   • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
     • Observation(s): There does not appear to be a system in place to ensure that residents who leave the facility for a temporary reason have some sort of written identification with them as per section 56(1)(2) of the RCR.
     • R10.2L - 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 )
   • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): The system for ensuring that residents identified as being an elopement risk have a an elopement care plan in place appears to be ineffective. Licensing noted a resident identified as being an elopement risk had some interventions in place, however, this was not outlined in a care plan. The system for ensuring that the activities of daily living (ADL) care plans were current appeared to be ineffective. Upon a random audit, licensing noted numerous ADL plans did not have a date and therefore licensing was unable to ascertain whether or not the plans were current.
     • 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)
     • 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. Substantiated complaintSep 20, 2022

   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 complainant stated that care conferences were not occurring. Licensing reviewed the licensee’s policy for care conferences. The licensee confirmed that care conferences had not consistently been occurring as per the policy. Licensing finds this complaint to be substantiated.
     • 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 complainant alleged that all staff have not been trained in emergency preparedness. Licensing reviewed the record of drills and confirmed that, although drills are occurring now, they were not consistently being completed the past 6 months.
     • R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
7. Substantiated complaintJul 15, 2022

   1 infraction

   • R4.5 - Are incidents and notifications reported and records retained as required?
     • Observation(s): The complaint received alleged an incident, which was reportable, was not reported to licensing as per section 77 of the Residential Care Regulation. Licensing reviewed the allegation of delayed baths with the licensee and noted a service delivery incident had not been reported to licensing as required.
     • R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
8. Substantiated complaintJun 10, 2022

   1 infraction

   • R4.5 - Are incidents and notifications reported and records retained as required?
     • Observation(s): On May 16, 2022, Licensing received historical complaint information with concern for required reportable incident notification to Community Care Facility Licensing (CCFL). A review of facility records and documentation confirmed a reportable incident was not submitted to CCFL in March 2021; complaint - substantiated.
     • 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)
9. Routine InspectionApr 7, 2021

   3 infractions

   • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
     • Observation(s): The system implemented following previous inspection for ensuring all persons admitted to the facility have clear and up to date immunization records appeared to be ineffective. In review of the records for admissions, licensing officer noted that the area noted for immunization statuses remained blank.
     • 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
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): PRN effectiveness was noted to be inconsistently documented.
     • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
   • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): During inspection it was noted that behavioural care plans displayed in person in care's rooms were not consistently updated.
     • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
10. Routine InspectionFeb 19, 2020

    3 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The system for ensuring all persons admitted to the facility have clear and up to to date immunization records appeared to be ineffective. In review of the records for recent admissions, licensing officer noted that the area noted for immunization statuses were blank.
      • 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
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): During the inspection, it was noted that there has not been a recent medication room inspection. The licensee is currently in the process of changing pharmacies.
      • R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(b)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system for ensuring ID (as described in Section 56(1)) is provided to persons in care who leave the facility for a temporary purpose appeared to be ineffective. Currently, when persons in care leave the facility for a temporary purpose, they are taking ID which only includes information about the facility.
      • R10.2L - 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 )
11. MonitoringJun 6, 2018

    2 infractions

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Upon a random audit of resident rooms, a disposable razor was noted to be accessible to persons in care.
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The system described by the licensee to ensure that residents with aggressive behaviours are flagged and care planned for appeared to be ineffective. This was noted during a random audit of resident rooms. One resident had been flagged as having aggressive behaviours and did not have the purple behaviour care plan in their room.
12. MonitoringApr 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): There are clear and up to date records of pneumococcal and influenza vaccinations, however, there is limited information around resident's immunizations statuses beyond flu and pneumo.
      • 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
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system for ensuring performance reviews are conducted regularly is ineffective. Although many had recently been completed, numerous employees were overdue for their performance reviews.
      • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): The system for ensuring medication care plans are reviewed/revised when a change in resident status occurs appears to be ineffective.
      • 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)
13. MonitoringFeb 4, 2016

    4 infractions

    • 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): The resident complaint management policy does not direct complainants to contact licensing if needed.
      • Ensure there are written policies and procedures for how persons in care, their parents or representatives and contact persons may express concerns, make complaints and resolve disputes under section 60; 85( 2 )(d)
    • 4.6 Are facility records current and complete?
      • Observation(s): There has not been a recent audit reflecting residents' satisfaction with the food or food service.
      • Retain the results of monitoring of food services and nutrition care; 87(c)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The window in the resident kitchen is cracked. Please provide a plan to licensing by the above date as to when this will be addressed. Aerosol deodorizer spray was found to be in unlocked closets in two separate locations in the facility. CORRECTED DURING INSPECTION.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 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): Two residents who have been identified as having the potential to elope, did not have written elopement care plans in place. One resident's care plan in their room referred staff to their behaviour care plan. The behaviour care plan for that resident was not longer applicable.
      • 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)
      • 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)
14. MonitoringApr 15, 2015

    5 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): One resident was noted to have a restraint included in their care plan, however, consent to the use of restraints had not been obtained.
      • 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)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): An incident for aggressive/unusual behaviour and emergency restraint (as defined in schedule D of the Residential Care Regulation), had not been reported to licensing.
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77(2)(c)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): On resident was noted to have undergone an "emergency restraint" but LO was unable to find evidence of the appropriate follow-up documentation. The licensee is currently developing a policy to address this.
      • Train employees in alternatives to the use of restraints. They must be able to determine when alternatives are most appropriate, when to use restraints and how to monitor the use of them; 73(2)(b)(i)
      • Provide in a manner appropriate to the person in care's skills and abilities, information and advice in regard to the emergency restraint used; 73(3)(a)(i)
      • Provide each person who witnessed the emergency restraint with information and advice appropriate to the person's skills and abilities; 73(3)(a)(ii)
      • Document in the care plan, the advice and information given following the use of an emergency restraint; 73(3)(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The fridge in the resident kitchen had two thermometers, one was reading 6 degrees Celsius and the other was noted to have bubble leaks. CORRECTED DURING INSPECTION.
      • Ensure that food is safely prepared, stored, served and handled; 63 (1)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The fascia on a section of the building had broken away and fallen into the outdoor recreation area. CORRECTED DURING INSPECTION. Gardening tools were in the gazebo in the outdoor reactions area. CORRECTED DURING INSPECTION. A hose was coiled up on a section of the paved walkway in the outdoor areas. CORRECTED DURING INSPECTION. Coiled cords were handing in a common area closet. CORRECTED DURING INSPECTION. In two different supply cupboards, a flammable aerosol can and a can of deodorizer could be accessed by PICs. CORRECTED DURING INSPECTION. There was a brown substance (glue) smeared on the walls around the hand rails down one wing. A prescription ointment was found to be accessible in one residents' bathroom. CORRECTED DURING INSPECTION.
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
      • 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)