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Country Squire Retirement Villa

9705 87 St N Osoyoos BC V0H 1V2 · Residential Care - Licensing

Official record from Interior Health →

Inspection summary

Country Squire Retirement Villa has been inspected 9 times by Interior Health Authority since March 24, 2015. The most recent inspection, on December 17, 2024, recorded 5 infractions.

None of the 9 inspections on record were free of infractions. No inspections are on record from the past 12 months. All recorded findings relate to upkeep, equipment or paperwork rather than direct health risks.

Recent inspections have recorded fewer infractions than earlier ones, so the record is improving.

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 These findings are administrative: the documentation was missing or out of date at the time of inspection.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 15 times across 7 separate inspections, most recently on December 17, 2024. For example: 6 - Are facility records current and complete?

  • 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 6 times across 6 separate inspections, most recently on August 29, 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 17 times across 7 separate inspections, most recently on December 17, 2024. For example: 2 - Is the environment maintained to prevent falls?

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.

9 inspections

  1. Routine Inspection

    5 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): Licensing Officer observed a bathtub and shower which did not contain a slip resistant material.
      • R7.2P - Ensure bathrooms have slip resistant material on the bottom of each bathtub and shower; 30(b)
    • R4.6 - Are facility records current and complete?
      • Observation(s): Licensing Officer reviewed a staff file that did not contain the current copies of their FOODSAFE certification and Immunization screening.
      • R4.6L - Ensure all records are current; 91( 1 )(a)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing Officer observed a fridge and freezer used by persons in care where the temperature was not being monitored. This was corrected during the inspection.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Licensing Officer reviewed the process for self-administering medications along with a care plan for a person in care who was self-administering. The process for self-administering medications did not ensure compliance with the Residential Care Regulation as the proper approvals were not obtained and it was not properly documented in the care plan.
      • R9.1G - Permit self-administration of medication when a plan is approved by the medication safety and advisory committee and medical or nurse practitioner, and is included in the person's care plan; 70( 4 )(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): Licensing Officer reviewed a system that did not ensure fulsome behavioural care plans as applicable.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
  2. Routine Inspection

    5 infractions

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Licensing Officer observed the PRN medication effectiveness being charted contrary to facility policy. Licensing Officer observed incomplete forms in the staff files which included checklists, policies not signed, and orientation checklists. Licensing Officer also observed an incomplete ADL sheet in a person in care's chart, all of which was contrary to facility policy. Licensing Officer observed an expired first-aid certification in a staff file, contrary to facility policy. Licensing Officer observed the menu substitutions not being recorded as per facility policy.
      • 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): Licensing Officer observed a staff file that did not contain a criminal record check, work history, or any evidence of compliance with the province's immunization and tuberculosis control programs.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • R3.1D - Obtain a record of work history for all employed persons; 37( 1 )(c)
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing Officer observed three persons in care's charts, each of them were missing the admission heights and one had the admission weight.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Licensing Officer observed the posted menu did not match the food being served.
      • R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing Officer observed cleaning products stored in an unsecure manner under a sink. Licensing Officer also observed laundry chemicals stored in an unsecured manner.
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
  3. Routine Inspection

    4 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Licensing Officer observed records of two persons in care that did not have any immunization screening upon their admission.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Licensing Officer found that prior to admission, the persons in care or their representatives were not being given information on how to express concerns or make complaints to Licensing. Licensing Officer reviewed a staff file and found that performance reviews were only completed two of the last three years, which is contrary to facility policy.
      • 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)
      • R2.1S - 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): Licensing Officer observed 4 weeks worth of menus. It was observed that some of the breakfasts did not contain three food groups described in Canada's Food Guide. It was also observed that there were many snacks that did not contain two food groups described in Canada's Food Guide.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing Officer found during the inspection that there is no system in place to monitor the temperature of water accessible to persons in care.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
  4. Routine Inspection

    2 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): It was identified and confirmed that some past reportable incidents were not submitted to licensing. These will be submitted according the education provided.
      • 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Two of three employee files inspected were missing required records according to Section 37.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • R3.1C - Obtain character references for all employed persons; 37( 1 )(b)
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
  5. Monitoring

    1 infraction

    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Upon review of person in care's charts, the Licensing Officer was unable to locate information that described the person in care (in addition to a photograph) that could be used in case of emergency.
      • R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
  6. Monitoring

    1 infraction

    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The tub and shower room downstairs are still in need of repair (as per inspection report dated February 1, 2016). The Licensee stated these rooms are going to be renovated within the next few months. He also indicated that he will provide Licensing with a written plan prior to beginning the project. The emergency exit corridor downstairs was partially obstructed by a piece of furniture that was removed from a person in care's room. The Licensee acknowledged that the furniture needed to be moved and committed to doing so right away. Cleaning supplies noted to be accessible to persons in care at the time of inspection (one bottle found in the front entrance tub room and one bottle in the main floor linen closet). The Manager removed these bottles immediately when found (CDI). The Manager also provided education to new cleaning staff on the storage requirements for these cleaning products at the time of inspection.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
  7. Monitoring

    3 infractions

    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): When discussing the newly updated Emergency Plan, the Manager confirmed that the staff have not all received updated training and orientation to ensure they can implement the plan should there be any emergencies.
      • Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Temperatures for the fridges used for the storage of food are being logged daily; however, when the temperature is outside the acceptable temperature limits (greater than 40 degrees F) there is no indication as to the potential reason for this nor documentation as to action taken to rectify this issue of concern. This is a re-occurring infraction from the August 20, 2016 monitoring inspection. Undated left-over food observed in the kitchen walk in cooler. When asked, the kitchen staff stated that this food was prepared by the persons in care as part of the cooking program but was unsure as to when.
      • 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): Tub and shower rooms downstairs in need of repair: water damage evident on multiple walls; missing caulking along the edges of the bathtub and tiles; and, rust observed on: the base of the bathtub in the tub room, on the shower room curtain rod, call bell housing and towel rack legs. The kitchen area used by residents for the cooking program or for personal use is in need of cleaning and sanitizing: cupboards, drawers and shelves were observed to have dried food, drinks and crumbs in/on them; and, dishes stored on open shelves and used for cooking or eating had dust and stains on them. The fire extinguishers throughout the facility are tagged as being due for the next service in January 2015.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
  8. Monitoring

    5 infractions

    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): OUTSTANDING from 30-Oct-2014; 20-Aug-2015 - It was noted that some residents had missing immunization screening records.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 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): 20-Aug-2015 - It was noted that the emergency plan did not refer to the current Residential Care Regulation.
      • Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): OUTSTANDING from 24-Mar-2015: 20-Aug-2015 - It was noted that immunization status of the residents is not always recorded.
      • 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
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): OUTSTANDING from 24-Mar-2015; 20-Aug-2015; Fridge temperatures are generally logged daily however temperatures of 48 to 59 degrees F are recorded with no documentation or indication of intervention. NEW INFRACTIONS from 20-Aug-2015; It was noted that some food items were being stored in the medication fridge. It was noted that the medication fridge temperature was not being logged.
      • 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): OUTSTANDING from 24-Mar-2015; 20-Aug-2015; One resident's room noted to have a chair with a torn seat, and water damaged flooring. A previously noted hole in the bathroom ceiling has been resolved. NEW INFRACTIONS from 20-Aug-2015; It was noted that one outdoor bench had rough, chipped paint. It was noted that a mat in the downstairs hall exit was curled at the edges posing a tripping hazard. It was noted that an outdoor area at the downstairs hall exit (wall, canopy, and light fixtures) was heavily covered in cobwebs. (The Licensee reported that this would be cleaned immediately.) It was noted that one resident's room was noted to have cobwebs in the corners, and the bedding was in need of changing. It was noted that a utility room containing paint and tools was unlocked and accessible to the residents. Corrected During Inspection (The Licensee reported that a service person had just finished working in that area)
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Each bedroom must meet the needs of and provide for the health, safety and dignity of the occupant; 26 ( 1 )
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
  9. Monitoring

    12 infractions

    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): 24-Mar-2015-Resident's TB and immunization screening records-This remains OUTSTANDING from October 30, 2014.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 (1)
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 8 - Is there access to a fair, prompt and effective process to express concerns, make complaints or resolve disputes within the facility?
      • Observation(s): Comments regarding the complaint process are in the main body of the report.
    • 17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): 24-Mar-2015-Corrected During Inspection - the Manger printed and posted the most recent routine inspection record.
      • 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)
    • 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): 24-Mar-2015-Emergency plans have been updated to include emergencies other than fire, however the policy still requires a plan for how residents will continue to be cared for in the event of an emergency. 24-Mar-2015-PRN effectiveness is not always documented as per RCR 85(1)(d) and RCR 70(Administration of medication). 24-Mar-2015-OUTSTANDING from October 30, 2014 - Resident care plans are not updated as per facility policy.
      • Prior to admission, advise of policies respecting: expressing concerns, making complaints, and resolving disputes; 48(1)(b)
      • 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)
      • 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): 24-Mar-2015 OUTSTANDING from October 30, 2014 - missing food safe certificates. 24-Mar-2015-missing staff performance evaluations.
      • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37(1)(d)
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40(1)(a)(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): 24-Mar-2015- It was noted that immunization status of the residents is not always recorded.
      • Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78(1)(a) Director of Licensing Standards of Practice: Immunization records
    • 4.6 Are facility records current and complete?
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 (1)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): 24-Mar-2015-It was noted that fridge temperatures were not being logged daily at times.
      • 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): 24-Mar-2015-OUTSTANDING from October 30, 2014 - water damage to downstairs tub room. 24-Mar-2015-water temperature measured 60.3 degrees Celsius on this day, and is to be adjusted immediately. 24-Mar-2015-One resident's room noted to have a chair with a torn seat, water damaged flooring, and a hole in the bathroom ceiling.
      • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): 24-Mar-2015-Unable to locate evidence of Medication Safety Advisory Committee.
      • Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68(1)(a)(b)(c) (Show More)
      • Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68(2)(a)(b)
    • 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): 24-Mar-2015-OUTSTANDING from October 30, 2014 - some care plans were noted to not have been reviewed within the past year.
      • 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)

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