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Gaumont Residence

1070 North Glen Dr Kamloops BC V2B 5C1 · Residential Care - Licensing

10 inspections

  1. Routine Inspection

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): RCR 37(1)(b) Two staff hired within the previous six months did not have a sufficient number of reference checks completed and present within their staff file. When staff are hired and reference checks are not completed fully, this increases the risk of hiring staff to work with persons in care that are not suitable. Submit an action plan of how the Licensee will come into compliance with current and future hiring practices no later than February 18, 2026. RCR 40(1) A review of staff files showed performance reviews having been completed in 2024, but not 2025. The Licensee’s policy is to have annual performance reviews completed. When performance reviews are not completed on a regular basis, this increases the risk of inappropriate care being provided to persons in care. Submit an action plan of how the Licensee will ensure performance reviews are done on an annual basis, per policy, no later than February 18, 2026. RCR 68(4) A review of the medication administration records for January 2026 showed multiple medications were not signed for. *This is a repeated contravention. When staff have not documented when medications have been administered, or a reason they were not administered, this increases risk of double dose of medications being administered to persons in care. Submit a corrective plan which will outline the systems that will be put into place to ensure all staff who administer medications document appropriately no later than February 18, 2026.
      • R3.1C - Obtain character references for all employed persons; 37( 1 )(b)
      • R3.1N - 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)
      • R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
  2. Routine Inspection

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): During the inspection the manager spoke about a person in care having recently been to the emergency room. Licensing had not received a reportable incident for the emergency room as per the facility file review completed prior to the routine inspection and informed the manager of same. The manager said they didn't know that kind of emergency room transfer would be needed because staff took them to the emergency rather than an ambulance. When reportable incidents are not reported immediately, as per legislation, this increases the risk that the approach of the Licensee may not be as fulsome as is required to ensure safety of all persons. Submit a detailed corrective action plan no later than August 28, 2025, for how all reportable incidents will be reported immediately to Licensing and knowledge of the definition of reportable incidents will be provided to staff. In addition, a review of all documentation for the last six months is required to be completed, and any incidents which meet the definition of reportable will be 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)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Review of persons in care charts did not include evidence of immunization or tuberculosis screening had been completed for persons in care. The manager stated they were not aware of whether or not all persons in care had been screened for tuberculosis or information gathered for their immunizations, but all persons have had covid and influenza vaccines or have documentation of refusal. When persons in care have not been screened as per the Province's immunization and tuberculosis control programs, this increases the risk of illness being able to be transmitted within the facility. Submit a detailed corrective plan of how all persons in care will be screened and the Province's immunization and tuberculosis control program will be followed, no later than August 28, 2025.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): RCR 37(1)(d) Renewable certifications of staff were reviewed and the current process to ensure all renewable certifications are kept up to date was discussed. One staff had an expired first aid certificate and was the sole staff working on one shift. The manager told the Licensing Officer that while she does look at the certificates, there is not a formal tracking process in place to ensure renewable certifications are not expired. Staff working with expired or a lack of valid certification increases risk to persons in care as the Licensee has not ensured required training and skills are in place for staff. Submit a detailed corrective plan of how you will ensure all staff employed at the facility have current and valid certifications by August 27, 2025. RCR 68(4) Review of the August 2025 medication administration records for persons in care showed three medications were not signed for. Additionally, one medication for one person in care was signed for as though it had been administrated daily for 6 days consecutively, but instruction of the medication to be taken once weekly. When medication administration is not accurately documented increases the risk of medication errors occurring, which increases safety risk for persons in care. Submit a detailed corrective plan of how you will ensure staff are following the medication safety and advisory committee's policies and procedures by August 28, 2025.
      • R3.1E - Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37( 1 )(d)
      • 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): Records of money being kept on behalf of persons in care were reviewed with the manager and found that entries of money withdrawn or put into the account from the fund for one persons in care were accurately captured, the "account balance" was not added correctly. When person in care's financial record is not accurate it increases the risk of financial mismanagement of the person's money being kept at the facility. Submit a detailed corrective plan of how you will ensure all person in care's financial account records will be kept accurate and up to date by August 28, 2025.
      • R4.1N - Keep a record of all money, valuables and other things held by the licensee in trust or safekeeping for persons in care; 79( 1 )(a)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Water temperature was measured for the the result of 54.1 degrees Celsius in the bathroom used by persons in care. Hot water that exceeds 49 degrees Celsius increases the risk of scalding persons in care and creating injury. Submit a detailed corrective action plan no later than August 28, 2025 that will explain how the Licensee will ensure hot water temperatures will not exceed 49 degrees Celsius.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
  3. Routine Inspection

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The manager had submitted an accepted Health and Safety Plan in October 2023, which included behavior management education for the employees. During this inspection, it was discovered the education that the manager had agreed to provide for employees had not yet been provided, and until this inspection, no notification was provided to Licensing that the accepted Health and Safety plan was not followed.
      • R1.1S - Provide a plan to ensure health and safety of persons in care during an investigation; 12 ( 2 )
    • 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 facility emergency evacuation plan did not include a plan for evacuation to a place outside of the community.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): RCR 79(1)(a) - The facility was not able to provide a policy regarding money management and documentation of the money where the facility held money other than rent for persons in care, and did have a regular practice to assist persons in care with their money. RCR 80(1) - A review of the care plan policy of the facility, showed no evidence that the policy directs employees to have a short term care plan in place at admission, as required by legislation.
      • R4.1N - Keep a record of all money, valuables and other things held by the licensee in trust or safekeeping for persons in care; 79( 1 )(a)
      • R4.1R - Ensure a short term care plan is developed on admission that guides caregivers in protecting and promoting the health and safety of the person in care; 80 ( 1 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The Medication Safety and Advisory Committee medication area inspection document was not available at the time of the inspection.
      • 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

    3 infractions

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): A review of facility Medication Administration Records showed that medications were not signed for at 0800 on one date for persons in care multiple times. The facility has a process to double check signatures for administered medications are completed, but this was not followed either.
      • 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): A new admission recently moved in to the facility and had been present at the facility for many days, no care plan was available for review.
      • R4.1R - Ensure a short term care plan is developed on admission that guides caregivers in protecting and promoting the health and safety of the person in care; 80 ( 1 )
    • R10.1 - Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): The process of screening new admissions was discussed during the inspection. Staff present were unable to articulate the process used other than to inform that "they talk about whether or not the person will fit in". The staff did not provide any evidence of a formal screening process which included the considerations within the RCR section 47 or section 49.
      • R10.1D - Screen the person before admission to ensure they will receive both safe and adequate care; 47 ( 1 )
      • R10.1E - Ensure the screening process considers the training and experience of employees, the number of employees and patterns of employee coverage; 47( 2 )(a)
      • R10.1G - Ensure the screening processes considers the needs of the person, including any needs identified specifically in a care plan; 47( 2 )(c)
      • R10.1J - Assess each person in care on admission to determine the risk that they may leave the facility without notification of an employee; 49 ( 3 )
  5. Routine Inspection Follow-up

    3 infractions

    • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Facility provides recreation opportunities for persons in care, however there were no available schedules of ongoing activities available for persons in care for the months of September, October or November 2023. Ensure there is a regular schedule of recreation activities which is developed in conjunction with person in care recreation care plans, and person in care attendance in activities is charted. This is a repeated contravention.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): A review of Medication Administration Records and the "Meal Substitutions list" showed that each of these documents had one missing entry. When discussed with the manager, there is not a current auditing process for documentation that is completed on a regular basis to ensure compliance with completing documentation of care by employees (licensee self monitoring process).
      • 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): A review of the facility's policies and procedures manual showed evidence of some of the documents having been reviewed, as they had a statement included at the bottom of the page "reviewed on {date}". However, the majority of the policies did not have any evidence (documentation) to show when they were initiated or if they had been reviewed since initiation on an annual basis, by the Licensee. One policy was noted to have statements included in it that upon discussion with the manager, it was agreed that they were requiring revision as they were no longer accurate to the current practice of the facility and required immediate revision to ensure proper practice is followed.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
  6. Routine Inspection

    9 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): For medication administration policies -PRNs- staff are recording under the response column different data than indicated within PRN policy. For example: Staff recorded "went to bed" as a response for PRN administration.
      • R2.2D - Ensure there are written policies and procedures regarding monitoring of the medications of persons in care; 85( 2 )(h)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Facility did not have an "internal incident log" available during the inspection.
      • R4.5H - Retain a record of all minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents; 88(a)
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): The bathtub did not have any slip resistant material applied, and no slip resistant mat was available at the facility during the inspection.
      • R7.2P - Ensure bathrooms have slip resistant material on the bottom of each bathtub and shower; 30(b)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Evidence of ongoing self monitoring of systems for physical environment, care and services was not provided during the inspection.
      • 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): Policies provided for review during inspection had no evidence of having been reviewed since they had been written, several years prior to the inspection.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Two staff files provided for review did not have the correct Criminal Record Reviews, as per the Canadian Criminal Record Review Act.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The facility provided a hand written, incomplete menu, which they write daily, using a menu on which not all meals have at least three food groups shown. This menu showed no evidence or documentation of seasonal review/changes and was difficult to follow. The menu provided for review did not show evidence of all snacks having at least two food groups included. The substitutions list provided did not show substitutions of the same food groups. There was no evidence of review of the meal plans showing they meet the required daily nutritional needs of persons in care.
      • 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)
      • R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
      • R5.1S - Provide adequate food to meet the personal nutritional needs based on Canada's Food Guide, and the person in care's nutrition plan; 66 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): In one area of the facility, there were missing baseboards, and a telephone hookup cover hanging from the wall. In one bathroom, there four areas of black/brown discoloration noted along the edge of the tub, within the caulking. One of the bathroom cupboards had water and shavings of some dark colored material present under the sink, which had been unknown to manager. The downstairs outdoor emergency exit stairs had a hose left at the top, which was present in the pathway of egress. All fire extinguishers present in the facility did not have any evidence of having been inspected or serviced on an annual basis and facility was unable to provide evidence of when the present fire extinguishers were originally purchased. In the dining area, there was a laundry soap pod left on a shelf, which was accessible to persons in care. In the outdoor common area, there was a large bucket of tar present, accessible to persons in care, which was reported by staff to have been present since they completed renovations in 2021.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • 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 )
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
      • 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): One of the care plans provided for review showed no evidence of a recreation care plan included. 8 of 8 care plans provided had no start dates included. Approximately 3 of 8 care plans had no evidence of review and modification present on a regular basis.
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
      • 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

    6 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): A corner kitchen cabinet door was observed as missing/broken during this inspection, ensure the cabinet door is fixed/replaced. Laundry facilities are used by persons in care, ensure non slip surfacing is in place in the laundry area.
      • R7.2N - Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
      • R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
    • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Facility provides some recreation opportunities to persons in care, however there is no current schedule of ongoing activities. Ensure there is a posted regular schedule of activities developed in conjunction with person in care recreation care plans/interests, and ensure person in care participation in facility recreation activities is charted. This contravention was noted during the last routine inspection of the site and was initially corrected but has not been maintained.
      • 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)
    • 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 policy indicates care plans will be reviewed annually, several care plans reviewed during this inspection had not been reviewed since June 2021.
      • 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): Annual staff performance reviews were noted to be overdue at the time of this inspection.
      • 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)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): Some employee Criminal Record renewals are overdue due to an issue with submitting to the Criminal Record Review Program using the facility number, Facility is working with the Criminal Record Review Program to resolve the issue. Staff immunization history and COVID proof of vaccination not available (although confirmed to be complete for all staff) on site for review during this inspection. Please ensure staff files are made available upon request and include: Immunization history, criminal record checks, resume, any applicable certificates, valid first aid certificate and performance evaluations.
      • R4.4A - Keep employee criminal record check results; 86(a)
      • R4.4C - Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Facility has a MSAC in place, however the last meeting with the Pharmacist was in June 2021 with no scheduled next meeting in place. Ensure a new MSAC meeting is scheduled as per facility policy.
      • R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(b)
  8. Routine Inspection

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Several incident reports received by licensing over the last year were not received immediately, please inform licensing on what changes will be made to current facility incident reporting procedures to ensure they are reported to licensing in a timely manner.
      • 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)
    • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Facility provides recreation opportunities for persons in care, however there is no current schedule of ongoing activities available for persons in care. Ensure there is a regular schedule of recreation activities which is developed in conjunction with person in care recreation care plans, and person in care attendance in activities is charted.
      • 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)
    • 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): Persons in care with behaviours have a behavioural care plan in place, however the plans reviewed during this inspection did not include behavioural interventions and were not updated on a regular basis.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
  9. Routine Inspection

    2 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): PRN effectiveness was not consistently charted in the Medication Administration Records (MAR) reviewed during this inspection. This contravention was noted during the last Licensing visit and has not been resolved. Inform licensing on what systems will be put in place to review MARS on a regular basis to ensure PRN effectiveness is charted.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): There is currently no system in place to ensure employee CRC's are renewed prior to expiring. Inform Licensing on what system/audit will be put in place to ensure CRC's are renewed prior to expiring.
      • R4.4A - Keep employee criminal record check results; 86(a)
  10. Routine Inspection

    2 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): PRN documentation observed and discussed with the facility manager was not originally charted correctly by staff to include the reason and result of the medication. The charting was later followed up on by the facility RN. Inform Licensing on what staff education follow-up will be taken to ensure staff are trained on the correct PRN documentation procedures, also include how medication charting is audited on an on-going basis.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(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): The current monthly recreation calendar was not posted at the time of this inspection. PIC's do have individual recreation plans, but the daily charting observed does not always include what steps have been taken to try and meet the goals identified in the recreation plan. Inform Licensing on what systems/audits will be put in place to ensure recreation options are offered to PIC's.
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)