Garden Manor Rest Home
63 Nicola St W Kamloops BC V2C 1J5 · Residential Care - Licensing
10 inspections
- Routine Inspection
2 infractions
- R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
- Observation(s): Facility did not have evidence of planned recreational activities for PIC. When planned activities are not available to PIC, there can be negative overall health impacts including social isolation, depression, increased anxiety, and poor physical condition. Submit a corrective action plan by February 6, 2026, to indicate how the facility is providing a program of activities suitable to meet the needs of PICs.
- R8.1A - Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55( 1 )(a)(i)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): In person in care (PIC) charts, there was no evidence of written consent from the PIC, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness. If written consent from PICs for medical treatments is not obtained, it could cause a delay in medical treatment or potentially become a liability concern. Submit a corrective action plan by February 6, 2026, indicating what systems are in place to ensure consents are in place for all PICs.
- R4.1L - 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)
- R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
- Routine Inspection
1 infraction
- R8.2 - Does the program of activities support individualized care plan requirements?
- Observation(s): Facility recreation programming was discussed during this inspection, some group activities are occurring that are not being documented, as well as one to one activities which are not charted/documented. Please review the site recreation program, to ensure programs and one to one outings are in place to meet the needs of persons in care, and the activities are documented to allow for review as needed.
- R8.2A - Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55( 1 )(a)(ii)
- R8.2 - Does the program of activities support individualized care plan requirements?
- Routine Inspection
1 infraction
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): The system to ensure fridge and freezer temperature monitoring policies are implemented by employees is ineffective. It was observed, in several instances, that fridge and freezer temperature documentation were missing.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(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?
- Routine Inspection
0 infractions
- Routine Inspection
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): Facility emergency evacuation plans include an emergency travel kit, some information in the kit observed during this inspection had not been updated to reflect current PIC information. Ensure facility emergency preparations include regular review/updating of the emergency travel kit.
- R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Employee performance evaluations are currently behind schedule, inform licensing on what steps will be taken to ensure overdue evaluations are completed and a system is in place to complete future reviews on schedule.
- 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)
- 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?
- Routine Inspection
2 infractions
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): PIC who can leave the facility independently are provided ID, however there is no consistent process in place to audit to ensure PIC have their ID on them when leaving 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 )
- 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): It was noted that one care plan reviewed indicated a weekly monitoring plan for a PIC regarding a health issue, however charting indicated one of the weekly checks was not completed/charted.
- R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Routine Inspection
1 infraction
- 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): Recreation care plans are in place, however the progress note documentation does not include information on the facility is attempting to meet the goals/needs indentified in the plan. Inform Licensing on what systems/audits will be put in place to monitor if the recreation care goals for each PIC are being met.
- R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(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?
- Monitoring
2 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Medication administration records were reviewed during this inspection, some MARS showed days in which a medication was not charted, please review/update procedures for auditing missed med charting. Inform Licensing on what changes have been made to the system and how the system will be audited to ensure charting is completed.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Weekdays between 0700 and 0800 the facility currently does not have a staff on site who has valid first aid/CPR. Inform licensing on how this will be resolved.
- 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)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
3 infractions
- 7.2 Is the environment maintained to prevent falls?
- Observation(s): Some of the slip resistant material in the downstairs bathtub has peeled off, ensure all bathtubs and showers have slip resistant material in place.
- Ensure bathrooms have slip resistant material on the bottom of each bathtub and shower; 30(b)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): An informal process is currently in place for performance managing RN's, ensure a policy is development in regard to the frequency and process for all RN performance evaluations.
- Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- 4.6 Are facility records current and complete?
- Observation(s): Please review wound care documentation and plans to ensure a consistent approach is in place for all wound care plans.
- Ensure all records are current; 91( 1 )(a)
- 7.2 Is the environment maintained to prevent falls?
- Monitoring
6 infractions
- 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
- Observation(s): TB test missing in one staff file reviewed. Ensure all staff have a TB clearance prior to commencing work at facility.
- Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 5 )
- 7.2 Is the environment maintained to prevent falls?
- Observation(s): PIC's do not generally utilize laundry facilities but they do have access to the area, ensure slip resistant floor surface is in place or ensure PIC's to do not have access to the laundry area.
- Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
- 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): Medication administration procedure observed during this inspection does not align with with procedures documented in facility medication administration policies. Please review medication procedures and ensure all staff are trained on and follow facility medication procedures.
- Establish and review policies and procedures on safe and effective storage, handling and administration of medications; 68( 3 )(b)(i)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Facility policy is to conduct annual performance evaluations of all staff, facility is currently 6 months behind on annual evaluations. Please submit a plan as to when all staff performance evaluations will be completed.
- 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)
- 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Identification is available for PIC's who leave the building independently but it is not always being utilized. Develop a procedure to monitor if PIC's have identification when they leave the facility.
- 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 ) ( 22 )
- 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): A care plan reviewed contained conflicting information, review each care plan is to ensure the most recent information for PIC's is available for staff.
- Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
- 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?