Marjorie Willoughby Snowden Memorial Hospice Home
72 Whiteshield Cres S Kamloops BC V2E 2S9 · Residential Care - Licensing
10 inspections
- Routine Inspection
2 infractions
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Review of several medication administration records (MAR) shows multiple medications are not signed for, or indicated that they were refused by persons in care at the time of administration. When medications administered or refused are not signed for as per Licensee's policy, this increases the risk of improper medication dosage, and increases the risk of double doses being administered. Submit a written action plan of how the Licensee will ensure all staff are following the medication administration policies, no later than April 13, 2026.
- R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Person in care charts reviewed and there was no consent to seek a higher level of care was found in any of the charts. When a person in care, or their representatives, have not provided written consent to seek a higher level of care in situations where the Licensee is unable to provide appropriate care, this increases the risk to persons in care and their health, safety and dignity. Submit a written action plan of how the Licensee will ensure consents are appropriately obtained per the legislation, no later than April 13, 2026.
- R10.2C - Persons in care can only be transferred to another facility with the consent of the person in care, parent, or representative, unless the person is on leave under the Mental Health Act; 50( 2 )(b) ( 23 )
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Routine Inspection
3 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The manager reported that the facility had heat pumps installed into each of the person in care rooms. No notice or health and safety plans had been submitted to Licensing prior to the project implementation.
- R1.1C - Submit health and safety plan to licensing and receive written approval prior to making any structural changes; 8( 2 )(a)(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): A review of the documentation of meals served showed food temperatures were not taken for several documented meals over the last week. The facility has a written policy instructing all employees and volunteers to take all food temperatures before serving food.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): A review of person in care files showed height and weight is not included as part of the admission data gathered. A review of person in care files showed evidence that pictures and physical descriptions were not collected as part of admission data. This was a confirmed current practice of the facility for all persons in care.
- R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
- R4.1I - 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)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection
3 infractions
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): A review of a person in care's care plan showed evidence of use of a restraint intermittently. There was no documentation of monitoring of restraints while restraints were applied to persons in care.
- R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): The facility was unable to provide documentation of fire drills and emergency drills having been completed.
- R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The facility could not provide a policy to guide staff on how to assess whether or not a person in care who smokes cigarettes would require supervision, especially in cases where the person in care's level of care needs changes.
- R7.1O - Ensure that if necessary for the safety of the person in care, a person in care who engages in restricted consumption is supervised.; 23(2)(c).
- R4.3 - Is documentation concerning restraints adequate?
- Routine Inspection
3 infractions
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): During the inspection of the facility's pantry, there were two food items found that had expired dates.
- 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 one tub room, there was a table with two pair of nail clippers and a pair of nail scissors without labels. It was discussed that these items are used for multiple persons, cleaned between uses with a cleaning liquid usually used for tubs. The cleaning process was not posted in the bathroom and could not be provided during the inspection for review.
- 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)
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): Evidence was provided to show the Medication Safety Advisory Committee had met and the medication rooms inspections completed on February 1, 2023. There was no evidence of any previous meetings or medication room inspections available and as a result, the frequency of the meetings and med room inspections was unable to be determined over the last three years.
- R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(b)
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- 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 had recently updated complaint procedures, information on how to contact licensing if not satisfied by facility follow-up was not included. Resolved at the time of this inspection.
- R2.1J - Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(a)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Facility tracks and keeps records of the meals served, however if a PIC chooses not to eat the main meal provided and is offered a secondary choice, this is not necessarily charted. Please develop a process to document the meals provided if a PIC is offered a secondary meal choice which can be reviewed at a later date if required.
- R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
- 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
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Some missed charting observed in facility MAR's. Facility has a review process in place to monitor MAR's and PRN documentation, however some missed charting was observed during this visit. Inform Licensing on what systems and audits will be put in place to ensure MAR charting is completed.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Some staff files reviewed/discussed do not include a copy of a TB TST result. Ensure hiring processes include receiving a copy of TB TST for all staff.
- R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
3 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): PRN charting for medication effectiveness was observed as inconsistently charted during this visit, inform licensing on how this item will be resolved including what systems and audits will be put in place to ensure charting is completed.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Facility has planned dinner and lunch meal service but they will change the meals frequently to meet the requests of the residents in care. Facility procedure is to document what is served for lunch and dinner meal service, several omissions to meal documentation were observed during this inspection. Inform Licensing on what systems and audits will be put in place to ensure facility meal documentation is completed.
- R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): Handwritten medication administration records observed during this inspection, please review with your MSAC a process to ensure the Pharmacist records all medication on resident MAR's. Inform Licensing on what changes will be made to the MAR procedure to be in compliance with RCR 69(1)(b)
- R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
3 infractions
- 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): Facility emergency evacuation procedures include a plan to evacuate to a secondary location that is adjacent to their site, please review this procedure and add another evacuation location which is a further distance from Marjorie Willoughby Snowden Hospice in case the emergency requires an evacuation of a further distance.
- Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
- 4.4 Are records kept on each employee with the necessary requirements?
- Observation(s): Two newly hired staff files discussed during this inspection did not have criminal record clearances, both had been sent off; but the clearances had not been received. Facility will review its CRR application process to determine if changes could be made to enable receipt of the clearances to happen more quickly.
- Keep employee criminal record check results; 86(a)
- 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): Facility policy includes daily auditing of food temperatures, one of the audits reviewed included temperatures which were not in the optimal storage range for refrigerated foods (0-4 degrees Celsius), ensure the audit procedure includes steps for staff to take when the temperature recorded is not in the optimal range.
- Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- 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?
- Monitoring
2 infractions
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Several PRN's reviewed in facility MAR's did not include charting for the reason and result of the medication. Ensure PRN medications are charted for reason and result. This infraction has been noted on consecutive inspections.
- Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): One staff file reviewed did not include a copy of a criminal record clearance, ensure all staff have a copy of their criminal record clearances in their personnel file for review by licensing.
- Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?