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Highridge House

1099 Singh St Kamloops BC V2B 5E2 · Residential Care - Licensing

13 inspections

  1. Routine Inspection

    3 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): A person in care’s bed frame is found to have large, chipped areas in the wood paneling, with sharp edges exposed and accessible. When sharp edges are exposed and accessible to persons in care, this increases the risk of injury to persons in care. Submit no later than June 12, 2026, an action plan of how the Licensee will ensure monitoring the condition of and maintain furnishings of the facility.
      • R7.2M - Ensure furniture and equipment for use by persons in care are compatible with health, safety and dignity of the persons in care; 21(b)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Fridge/freezer temperature documentation is reviewed, and five entries are found to be missing for May 2026. The licensee’s policy indicates that temperatures are required to be recorded daily, and the manager confirms that all staff are oriented to complete and document the checks each day. When fridge/freezer temperatures are not checked as required, this increases the risk of spoiled food items, which increases risk of illness for persons in care. Submit no later than June 12, 2026, an action plan of how the Licensee will ensure staff are checking and documenting temperatures of the fridges and freezers in the facility.
      • 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): In the downstairs kitchen, a drawer containing knives and other sharp implements is not locked and is accessible to persons in care. When sharp implements are accessible to persons in care with possible cognitive impairments/behaviors, this increases risk of injury to persons in care or other persons in care. Submit an action plan no later than June 12, 2026, of how the Licensee will ensure sharp implements and other hazardous objects are kept inaccessible 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)
  2. Routine Inspection

    3 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): Sheets, blankets and other bedding materials were observed in a cupboard where there was no door or other cover to keep the items contained, and the shelves were over stuffed. A few of the blankets were observed as being stored directly on the floor. Having bedding materials in open areas, on the floor and accessible to persons in care increases the risk of items becoming contaminated, thereby increasing risk of illness to persons in care. Create an action plan by September 29, 2025, of how you will address the storage of supplies in ways to ensure the risk of contamination is mitigated ongoing.
      • R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): In the living room, the curtains were noted to be discolored and dusty. The manager could not recall if they had ever been cleaned before. The window was open with no screen in place and the portable air conditioner hose hanging out the window. In the basement there were several walls with holes ranging in size of approximately 10 to 15 centimeters in diameter. The walls had notable dirt marks, and/or worn paint in multiple areas, some with exposed drywall. Without regular preventative maintenance and cleanliness self monitoring actions being completed regularly the risk of injury or illness increases for persons in care. Create an action plan by September 29, 2025, of how you will address the self monitoring systems for the physical environment.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It was observed that the gate latch at the top of the patio stairs was not engaging unless the gate was lifted, therefore leaving the exterior stairs and the busy cross road accessible to persons in care. The stair hand railing on the exterior stairs was shaky when held onto. The same handrail was rusty and detached at the two bottom columns which should be secured in design. The railing of the patio along the long side was found to have cracks and sharp edges forming along the top rail with paint peeling away. The rail was found to be loose when gently pushed against. Inside, the half door located from the hall leading to the staff room had large sections of the door with exposed wood and peeled paint. Without regular maintenance and preventative maintenance practices being completed regularly the risk of injury increases for persons in care. Create an action plan by September 29, 2025 of how you will address the gaps found in the current maintenance system to ensure regular upkeep is completed within the facility.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  3. Routine Inspection Follow-up

    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): RCR 85(1)(d) –Interviews identified staff are not adhering to the Licensees policies for "Person Served Abuse Policy and Procedure" (reporting bruising on a person in care), and "Reporting, Recording, Charting Policy" (documentation of bruising). When staff do not follow the Licensee's policies for guiding care, this may increase the risk to the health and safety of persons in care. Submit a detailed corrective action plan for how you will ensure all staff are following the facilities policies no later than July 31, 2025.
      • 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): RCR 37(2)(c) - Two staff reported they did not see any bruises because they did "not look at them" (the person in care) when providing care and they "don't look, I just wipe". The risk to person in cares health and safety is greatly increased when staff are not knowledgeable of when and how to make observations of the persons condition and assess for changes that can affect their health. Submit a detailed corrective action plan of how you will ensure all staff have the appropriate knowledge and skills to provide appropriate care, including observing for changes in health, for all persons in care, no later than July 31, 2025.
      • R3.1I - Ensure that employed persons have the training and experience and demonstrate the skills to carry out duties assigned to the manager or employee; 37( 2 )(c)
  4. Routine Inspection

    1 infraction

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): RCR 17 -Water temperatures were tested during the inspection for a result ranging from 50.6 to 55 degrees Celsius. *This is a repeated contravention. RCR 22(1)(b) - The following areas were noted during the inspection to exhibit safety hazards in the physical facility: • One bathroom had a baseboard heater with rust on one edge and the front cover not attached • The basement flooring had many floorboards where the edges were “bowing” and creating sharp edges and/or tripping hazards. • One clothing cupboard was present in a common area and had one door removed, but the hinges remained in place. • In one bathroom, the toilet seat was leaning against the wall near the toilet, and the plastic bolts remained, broken, in the toilet itself. The bolts had sharp edges and the toilet was not useable. • The dining room table had laminate lifted in several areas of the tabletop, and one area where the laminate had been removed, exposing particle board beneath. • One kitchen door frame had large areas of wall border broken off, leaving wood and drywall exposed. RCR 35(1)(c) – In one kitchen the cupboard doors beneath the sink were detached, and leaning against the frame, leaving two bottles of cleaning products under the sink accessible to persons in care.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • 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)
  5. Routine Inspection Follow-up

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): A review of employee files showed the following: -Records of immunization control programs including childhood vaccinations screening, Hep B vaccine and evidence of annual flu shots/decline to receive annual flu shots were found in approximately half the employee files reviewed. Evidence of Covid vaccinations was present in all files. -One of the employee files reviewed had evidence of tuberculosis control programs screening, while no evidence of tuberculosis screening was not present in any other employee files. -The Licensee designate present at the inspection was not familiar with what the current provincial immunization and tuberculosis control program included. -Of the employee files that were reviewed one file showed no evidence of a performance review having been complete as per the policy of the organization. -Of the employee files reviewed, three files had first aid/CPR certificates which did not meet the requirements of Schedule C. The course taken did not include an "in person" portion, as it was an online program which does not meet Schedule C. Please be sure to fully review Schedule C when selecting a "preferred" first aid/CPR program for the organization.
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
      • 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)
      • R3.1R - 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)
  6. Routine Inspection

    5 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): During the inspection, there was a contractor (manager confirmed they were not a direct employee of the facility) present who was completing painting in the facility. No Health and Safety Plan had been provided to Licensing prior to the start of the project.
      • R1.1B - Submit plans for the change to licensing and receive written approval prior to making any structural changes; 8( 2 )(a)(i)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Several performance evaluations for employees are overdue. Inform licensing on what systems will be put in place to ensure probationary and regular performance evaluations will be completed according to organizational policy. This is a REPEATED contravention.
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): There were two bags which contained food found in a kitchen cupboard that were open and the contents exposed, as well as a frozen red liquid in the bottom of the freezer.
      • 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): Water temperatures were tested during the routine inspection and were noted to be 52.4 degrees Celsius. On the patio, an outdoor area designated for use by persons in care (PIC), there were multiple larger items present, including weathered and broken chairs, plastic bags, cardboard boxes, etc. It was confirmed by the manager these items were no longer for use in the facility and were to be disposed of.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 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): A review of monthly weights of PIC from February to June 2024 showed one PIC's weight significantly fluctuated from the month of February to March by 13 pounds, and there was no evidence of a follow up to the weight difference in the PIC's records.
      • R10.3S - Record in the nutrition plan the reason why a person in care has refused or is unable to be weighed and that immediate advice is sought of a health care provider when it appears that a person in care may have experienced a significant change in weight; 83( 5 )(a) (b)
  7. Routine Inspection

    7 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): One person in care's care plan for restraints did not include a current (annually reviewed) written agreement.
      • 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Several performance evaluations for employees are overdue. Inform licensing on what systems will be put in place to ensure probationary and regular performance evaluations will be completed according to organizational policy. This is a REPEATED contravention.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): A review of a person in care's care plan did not include a falls care plan when that person in care has been identified as a falls risk. A review of monthly weights of persons in care showed several gaps where monthly weights were not recorded. These gaps were noted to be outside of the time frame the facility's persons in care had been displaced, as well as while displaced. *This is a REPEATED contravention
      • R4.1Q - Ensure a care plan is developed within 30 days for persons in care admitted for more than 30 days; 81.1; Director of Licensing Standards of Practice: Advance Directives and Care Plans
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): A review of the facility menus (7 week rotation) showed several meals did not include a minimum of 3 food groups being offered for all meals. A review of the facility menus (7 week rotation) showed several snacks did not include a minimum of 2 food groups being offered for all snacks.
      • 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): Two food items were found in the facility kitchen that were in an open package and/or unlabeled with the date opened. These items were disposed of during the inspection.
      • 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): Three heater covers had fallen off the baseboard heaters, exposing to persons in care the sharp edges of metal present inside the heater. The heater covers were re-attached during the inspection. On the outdoor patio, there were several items present that had been removed from the facility during the floor which needed to be taken to the dump (Ie. furniture no longer suitable for the facility use).
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The facility was not able to provide evidence of Medication Safety and Advisory Committee having met in 2023, or 2022. There was also no evidence of medication storage area inspection having been completed in this time frame either.
      • 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

    4 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): During this inspection it was reviewed with the facility manager that Licensing had not received a reportable incident over the last year, the facility has been reporting to CLBC but not to Licensing. Please develop a reportable incident procedure for reporting to Licensing and ensure staff are trained on the procedure. LO directed the facility manager to the Interior Health incident reporting portal during this inspection.
      • R2.2F - Ensure there are written policies and procedures regarding responding to reportable incidents; 85( 2 ) (j)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Several reportable incidents over the past year were discussed during this inspection, due to the lack of a reporting procedure to Licensing they were not reported.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): PIC weight charting for the past year was reviewed in facility charting, monthly weights were noted as sporadically charted in the identified location.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Damage noted to the cabinet in PIC bathroom which was observed during the last site visit. Some holes observed in the wall in the downstairs living room which were present during the last inspection. The outdoor deck has peeling handrails which are in poor condition in several locations, during this inspection there was a contractor on site who was reviewing the work required to the deck.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  9. 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): Facility in the process of updating emergency training/drill process as a new manager is now in place and drills previously had not been completed according to policy. Emergency procedures was also noted out of compliance during the last routine inspection. Please review orientation procedures for new managers in regard to the review and understanding of the Residential Care Regulation/Licensing, including processes for reporting incidents utilizing the IH portal.
      • 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)
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Several performance evaluations for employees are overdue. Inform licensing on what systems will be put in place to ensure probationary and regular performance evaluations will be completed according to organizational policy.
      • 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)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Facility currently does not have a system in place to document when the posted menu is not followed. Discussion during this inspection also included the facility potentially updating their menu.
      • 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): Hot water measured at 54 degrees Celsius during this inspection, please submit a plan on what systems the facility has in place to ensure water accessible to PIC's does not exceed 49 degrees Celsius.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
    • 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 oral care plan reviewed during this inspection was found incomplete. One recreation plan reviewed during this inspection did not include any specifics for the person in care. Recreation planning/documentation was noted as out of compliance during the last routine inspection at this home.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
  10. Routine Inspection

    6 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Ensure Licensing is made aware of manager changes within 30 days. Licensing was not made aware of a recent manager change until contacting the facility and being informed a different manager was in place. Resolved at the time of this inspection.
      • R1.1E - Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
    • 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 procedures include once a month fire drills which should be completed and documented. The documentation of several fire drills could not be located at the time of this inspection.
      • 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): Charting of PIC weights was observed as being completed sporadically when reviewed during this inspection.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Frozen prepared food observed thawing on the counter at the time of this inspection, inform Licensing on what food safe training and auditing is in place for staff to ensure food is safely prepared, stored, served and handled.
      • 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): One exit to the home has an electrical cord taped to the floor just in front of the door, it was lifting up at the time of this inspection which could cause a tripping hazard.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 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): Daily charting reviewed during this inspection did not include any information in regard to PIC recreation programming completed within the home.
      • 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
  11. Routine Inspection Follow-up

    0 infractions

  12. Monitoring

    5 infractions

    • RB1.25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): One Care plan reviewed for a PIC who has been in care at the facility for more than 30 days, does not meet the requirements for a care plan (RCR 81). Inform Licensing on how the required care plan elements will be added to the care plan, also include what systems/audits will be put in place to ensure care plans for new admissions are developed within 30 days of admission.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Annual performance reviews for permanent employees are behind schedule, most noted as last completed in 2016. Inform licensing on what systems/audits will be put in place to ensure performance reviews are completed per company policy.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The photograph in the PIC chart for one PIC was blurry and would not be useful in an emergency situation for identification. Ensure every PIC has a clear photograph which is updated when needed for use during an emergency. One Care plan reviewed for a PIC who has been in care at the facility for more than 30 days, does not meet the requirements for a care plan (RCR 81). Inform Licensing on how the required care plan elements will be added to the care plan, also include what systems/audits will be put in place to ensure care plans for new admissions are developed within 30 days of admission.
      • 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)
      • R4.1Q - Ensure a care plan is developed within 30 days for persons in care admitted for more than 30 days; 81.1; Director of Licensing Standards of Practice: Advance Directives and Care Plans
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Temperature audits of facility refrigerators and freezers are currently being completed twice a month, ensure temperature audits are completed in timeframes which will ensure food is stored at optimal temperatures at all times. Include in your response how temperature tracking is audited.
      • 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): Care plans reviewed during this inspection had not been noted as being reviewed by the facility for over a year, facility policy indicates at least annual care plan reviews, inform Licensing on what systems/audits will be put in place to ensure care plans receive a full review at least annually.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  13. Monitoring

    2 infractions

    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): Facility has a system for documenting staff qualifications including expiry dates to help ensure all documentation is up to date, during this inspection one entry indicates a staff CRC had just expired, please review current procedures to ensure audits of the expiry dates are working. Ensure staff CRC is renewed.
      • R4.4A - Keep employee criminal record check results; 86(a)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Cleaner left in an unlocked cabinet in washroom, facility has physical environment self auditing procedures in place, ensure self monitoring checks include auditing of items which need to be kept inaccessible to residents.
      • 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)