Kamloops Seniors Village
1220 Hugh Allan Dr Kamloops BC V1S 2B3 · Residential Care - Licensing
13 inspections
- Routine Inspection
3 infractions
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): When reviewing restraint monitoring documents, bunch charting was observed (multiple checks documented at the same time). On some days reviewed, restraint monitoring documentation was incomplete. Lack of restraint monitoring and documentation in real time has the potential to cause physical and emotional harm to persons in care. Submit compliance plan by February 26, 2026, to indicate how the licensee will ensure the physical and emotional dignity and safety of persons in care is monitored and documented according to the restraint care plans in place.
- R10.4F - Employees administering a restraint must follow any instructions in the care plan of the person in care respecting the use of restraints; 73( 2 )(b)(ii)
- 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 all restraints are reviewed and documents signed annually by the medical practitioner and persons in care representative. One risk agreement reviewed had not been reviewed/signed by medical practitioner and persons in care representative since 2024. Persons in care health, safety and dignity may be compromised as person in care and/or family may not agree to the continued use of restraint. Submit compliance plan by February 26, 2026, to indicate how the licensee will ensure all restraint agreements are signed by a medical practitioner and persons in care representative annually per facility policy.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Staff bags stored in unlocked cupboard accessible to persons in care. When persons in care have access to staff belongings they may be exposed to medications, food, or potentially hazardous items that could be detrimental to their health. Submit compliance plan by February 26, 2026, to indicate how the licensee will ensure they provide secure, safe and adequate storage areas for all potentially hazardous items. Medicated cream stored in unlocked cupboard in persons in care washroom. When persons in care medications are not securely stored, there is potential for misuse of medication and negative health outcomes. Submit compliance plan by February 26, 2026, to indicate how the licensee will ensure all medications are safely and securely stored.
- 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)
- R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Substantiated complaint
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Licensing Direct received a complaint on June 9, 2025, with concerns regarding elevated bedroom temperatures in one section of Kamloops Seniors Village. Room temperatures must be kept at a safe and comfortable temperature for persons in care. Licensing requested and received a health and safety plan from Kamloops Seniors Village regarding monitoring of room temperatures and the well-being of persons in care until the bedroom temperatures were returned to safe and comfortable levels. The facility received a concern of elevated room temperatures from a family member on the evening June 7, 2025. Due to a communication error, the concern from a family member was not relayed to site leadership until June 9, 2025. Facility leadership was notified of the concerns of a staff member regarding elevated room temperatures on June 8, 2025, at that time the HVAC monitoring system was tracked but showed normal temperatures. On June 9, 2025, Kamloops Seniors Village audited room temperatures and realized the monitoring system was not functioning properly, and the temperatures displayed in the system were not reflective of the actual temperature in some areas of the building. As of June 11, 2025, the issue with the HVAC system has been addressed and the temperatures are now at a safe and comfortable level. Due to the HVAC monitoring system malfunction, the facility was not able to ensure temperatures were kept at a comfortable level for persons in care. Submit an action plan by July 8, 2025, indicating what systems and audits will be put in place to ensure the HVAC system is keeping temperatures at a safe and comfortable level for persons in care. RCR 16 - Complaint Substantiated.
- R7.1A - Room temperatures must be safe and comfortable; 16 ( 1 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Routine Inspection
2 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Incident reports submitted to Licensing Direct over the past year were reviewed prior to this inspection. Reports are generally received immediately, however at times are missing information regarding the events leading up to the incident, as well as facility actions in response to the incident. Please inform on what steps will be taken to improve the details included within submitted incident reports.
- 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)
- 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): Ensure any persons in care who are able to leave the building independently, including to smoke, have a care plan in place that gives information on the specifics of the process.
- R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Substantiated complaint
2 infractions
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): The complainant spoke to staff at the site in regard to concerns with the temperature being too warm in a person in care's room, they were not satisfied with the outcome and brought the concern to Licensing Direct. The temperature concern was not addressed by the facility until being contacted by Licensing due to lack of communication and/or implementation of facility dispute resolution procedures. The facility provided Licensing with a plan for corrective action, and updated staff education in regard to dispute resolution processes since this complaint was received. No further response is required at this time.
- R2.1L - Respond to all complaints, concerns, disputes promptly. 60(c)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Room temperatures must be safe and comfortable for the person in care. At the time this complaint was received, systems to ensure the bedroom temperatures were at a comfortable level for persons in care were not effective. The facility has responded appropriately during the course of this complaint investigation, and has updated their systems and audits to monitor temperatures throughout the building to allow for immediate follow-up if temperatures do not fall into the expected norms. No further response is required at this time.
- R7.1A - Room temperatures must be safe and comfortable; 16 ( 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?
- Routine Inspection
3 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): During this inspection a reportable incident was brought up that was not reported to Licensing or the representative for the person in care involved. Please ensure the incident is reported to Licensing as well as the person in care involved. Please ensure incident reporting policies are up to date and all staff are aware of Schedule D reporting requirements.
- R4.5B - Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77( 2 )(a)
- 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)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Charting observed in Point Click Care for a restraint was not reflective of the monitoring required in the restraint care plan.
- R10.4F - Employees administering a restraint must follow any instructions in the care plan of the person in care respecting the use of restraints; 73( 2 )(b)(ii)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): One of the dining servery area doors was observed as open with no staff present during this inspection. Within the servery area there were potentially hot serving trays as well as cleaners stored under the kitchen sink, access to this area by anyone other than staff could also present a food safe concern. Ensure any areas which may contain hazardous items/materials 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection Follow-up
0 infractions
- Routine Inspection
4 infractions
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): In one bathing room, there were three sets of un-labelled nail clippers kept on a common table near the tub. All other nail clippers present in room were kept in labelled baskets. This was corrected during inspection. DOC states she will follow up with staff to ensure all materials are appropriately labelled and/or kept in a labelled basket.
- R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): On review of one person in care's care plan, there was no evidence of a bathing care plan present as related to their specific needs, nor was there evidence of a bathing care plan in the person in care's assigned tub room. Ensure all persons in care have a bathing care plan present in their plans of care if they have specific extra ordinary needs.
- R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): In one person in care's personal bathroom, there were two disposable razors and one bottle of denture cleaner accessible to the persons in care. In a second person in care's bathroom, there were two bottle of denture cleaner accessible to persons in care. Ensure all hazardous items and chemical products are kept in a secure area, and not accessible to persons in care.
- R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): The facility informed licensing the facility is not currently up to date with their documentation of wound care processes. They also informed they are currently reviewing their processes and a plan is in the works. Ensure all persons in care with a wound have an updated and regularly reviewed plan of care in place, and the care is supervised as appropriate.
- 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
- R7.2 - Is the environment maintained to prevent falls?
- Substantiated complaint
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): The complaint received by Licensing on July 8, 2022, indicated persons in care in one section of the building had missed their scheduled baths, and they had not been made up. Upon review by Licensing this complaint has been substantiated, the facility has since updated their systems for reviewing the daily care completed, including baths scheduled versus completed. The system changes were submitted to Licensing for review, and were accepted.
- 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
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Routine Inspection
2 infractions
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Ensure outdoor areas are kept in clean and safe condition to allow them to be utilized during appropriate weather. One outdoor area viewed during this inspection needed the deck and tabletops to be cleaned in order for PIC's to utilize.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Ensure there is a system in place to encourage/assist persons in care to be examined by a dental health care professional at least once every year.
- R10.2J - Assist persons in care to obtain professional dental services as required; 54( 3 )(b)(ii)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Routine Inspection
4 infractions
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Restraint monitoring checks are being documented in the facility data system, during this inspection it was observed that checks are often charted much later after the check was completed. Please establish expectations regarding the timeframes for charting restraint checks after they have been completed, as well as an auditing systems of the checks to ensure compliance.
- R10.4F - Employees administering a restraint must follow any instructions in the care plan of the person in care respecting the use of restraints; 73( 2 )(b)(ii)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Some annual performance reviews for care staff are overdue, inform licensing on what systems will be put in place to ensure overdue reviews are completed.
- R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Facility generally holds Family and Resident Council meetings Monthly, due to COVID 19 the meetings have not been held. What processes will be put in place to hold virtual or teleconference meetings moving forward.
- R10.2R - Provide at least an annual opportunity for persons in care and their parents or representatives, family members and contact persons to establish councils or similar organizations to represent the interests of persons in care; 59(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): Facility policy is to complete annual care conferences for each person in care, during this inspection it was observed that several care conferences are overdue. Inform Licensing on what systems will be put in place to ensure care conferences will be kept up to date.
- 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)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Routine Inspection
4 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Treatment Administration Records reviewed with the facility DOC, some inconsistencies noted in regard to charting, inform Licensing on how this will be corrected.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Ensure any restraint being used (Bedrails) in the facility is documented in the care plan of the PIC involved and include the type and duration of the restraint.
- R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
- 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 were discussed during this inspection including evacuation protocols. Please review transportation plans in the event of a community evacuation and update evacuation procedures accordingly.
- 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Staff personal items (purse, backpack etc.) were observed in unlocked cupboards in an area accessible to PIC's. Ensure all items which could have potentially hazardous materials (medication, lighter etc.) are stored in a manner which will prevent PIC's from gaining access.
- 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)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
4 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Licensing is receiving reportable incidents in a timely manner, but some of the incident reports received do not include all of the required information, some items missing have included: notification times/dates, fall precautions in place, follow-up to incident, PIC DOB. Please review incident reporting procedures and inform licensing on what systems and audits will be put in place to ensure completed incident reports are received by 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)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Ensure the care plan for every resident who has a restraint in place includes the use of the restraint, its type, duration for its use and how often it is to be monitored. Include in your response how this will be monitored.
- R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Facility recreation staff may at times be with residents away from the facility, ensure a process is in place to have a person with valid first aid/CPR to be present during all recreation outings away from the facility. Include in your response what systems and audits will be put in place to monitor compliance.
- 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)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Ensure every resident who has been identified as a potential elopement risk and may not be able to identify themselves, has some type of identification which cannot be easily removed, indicating the person's name, facility and emergency contact information. Inform Licensing on what identification system will be put in place and include how it will be monitored.
- R10.2M - Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56( 3 )(a)(b) (Show More)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Monitoring
5 infractions
- R6.1 - Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
- Observation(s): TB test results not available in one staff file reviewed. Ensure hiring documentation process is reviewed to ensure all staff requirements are included in staff files, include the auditing plan for this process in your response.
- R6.1A - Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Criminal record clearance documentation not available in one staff file reviewed. Ensure hiring documentation process is reviewed to ensure all staff requirements are included in staff files, include the auditing plan for this process in your response.
- R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): A housekeeping cart was observed unattended with cleaners accessible, ensure all potentially hazardous materials are kept inaccessible to PIC's. Staff personal belonging's (purses, backpacks) stored in cupboards in care areas, staff personal items may contain hazardous materials (medication, sharps, lighter etc...) ensure staff personal items are stored in an area which is inaccessible to PIC's. Facility has a physical self monitoring process in place, ensure it is updated to review for the items noted above.
- 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)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): PIC's who have been assessed as an elopement risk must have some type of ID that cannot be easily removed indicating their name, facility name and emergency contact information. Include the auditing plan in your response to ensure ID's are always in place for PIC's assessed as needing them.
- R10.2M - Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56( 3 )(a)(b) (Show More)
- 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): Wound care documentation observed throughout the facility was inconsistent. Please review wound care policies and ensure all care areas follow the same wound care and documentation process. Inform Licensing on how this process will be audited. Ensure the care plan for those PIC's at risk for leaving the facility include a plan to prevent this as well as a plan to locate the PIC if they did leave the facility.
- R10.3G - Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
- R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
- R6.1 - Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?