Mountain View Lodge
951 Murray St Lillooet BC V0K 1V0 · Residential Care - Licensing
13 inspections
- Routine Inspection Follow-up
1 infraction
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): The Licensee confirmed that there are currently no annual opportunities offered in lieu of having an active family council where families and representatives are able to discuss their collective interests. When there is not an opportunity provided by the Licensee for families and representatives to discuss collective interests related to care of persons in care, this increases the risk of improper care being provided. Submit an action plan no later than July 2, 2026, of how the Licensee will come into compliance with the Residential Care Regulation section 59(b)(i)(ii).
- R10.2S - Provide at least an annual opportunity for councils, or if no council is established, as a group, to meet with the licensee to promote the collective and individual interests of the persons in care and involve the persons in care in decision making on matters that affect their day to day living; 59(b)(i)(ii) (Show More)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Routine Inspection
4 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): One person in care chart reviewed finds that the restraint agreement was last signed by the representative and doctor in 2023. When the restraint agreement is not reviewed and signed by all required parties on an annual basis, this increases the risk of inappropriate restraint use. Submit an action plan by June 16, 2026, detailing how the Licensee will ensure systems are in place and followed to ensure all restraint agreements are signed annually by both the person in care’s representative(s) and medical practitioner. *This is a repeated contravention from May 2025.
- 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)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The most recent routine inspection is not posted in the facility. Routine inspections from 2023 and 2024 are available and posted. When the current routine inspection is not posted and made available in a public area, this increases the risk of contraventions reoccurring. Submit an action plan by June 16, 2026, detailing how the Licensee will ensure the current routine inspection is posted and available.
- R1.1O - Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): A review of the current medication administration records (MAR) shows multiple instances where the effect of as-needed (PRN) medications is not documented. There are more than 20 entries of PRNs with no documented effect. When the PRN effect is not documented, this increases the risk of double dosing of medications being administered to persons in care. Submit an action plan by June 16, 2026, detailing how the Licensee will ensure the PRN effect is documented for all medications. *This is a repeated contravention from May 2025.
- R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Razors, nail clippers, scissors, and a metal nail file found in several person in care’s rooms. When persons in care have access to metal objects that are sharp, this increases the risk of injury to self or others. Submit an action plan by June 16, 2026, detailing how the Licensee will ensure sharp objects are not accessible to persons in care. *This is a repeated contravention from May 2025.
- 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)
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Routine Inspection
3 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): When reviewing person in care charts there was no evidence found in one chart of a written agreement with both representatives and medical practitioners for an intermittent restraint which was part of the person in care’s care plan. Use of restraints on a regular or intermittent basis must be discussed and agreed upon with both the person in care’s representatives and medical practitioners to ensure the restraint is the safest action to take for the person in care. Submit a plan to identify all restraints in all persons care plans and how you will obtain written documented agreement for use of restraints with all applicable parties no later than June 10, 2025. *This is a repeated contravention.
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): A review of the Medication Administration Records showed six PRN medication (as needed medication) effects documentation were missing. When documentation of the effect of a PRN medication is not completed, the risk of additional doses being administered when not indicated is increased, thereby increasing the risk of overuse of PRN Medications. Submit a plan to indicate how you will mitigate reoccurrence of missing documentation for Medication Administration Records to Licensing no later than June 10, 2025.
- R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): A set of small screwdrivers was found on a bookshelf in the reading area accessible to persons in care. Nail clippers, razors and scissors were found in four person in care’s rooms unsecured and accessible to persons in care. Medicated creams were found in three person in care’s rooms unsecured and accessible to persons in care. When a person in care has access to items such as tools, nail clippers and other sharp objects this increases the risk of injury to self or others. Persons in care having access to medicated creams increases the risk of ingestion of non-edible items, which may lead to medical complications. Submit a plan of how the facility will be monitored, frequency of monitoring and actions which will be taken when hazardous items are identified as being accessible, and how employees will be notified to Licensing no later than June 10, 2025.
- 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)
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Routine Inspection
2 infractions
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): A selection of person in care's charts were reviewed, and one chart had an incomplete tuberculosis screening form present. The form was completed while Licensing remained onsite, therefore this was "corrected during inspection". The facility processes include screening for tuberculosis at admission. Facility to ensure follow up for completion of admission papers.
- R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): There is a door leading from the staff café area to outside the building that is kept unlocked (due to being a path of egress in emergency, as indicated by local Fire Department) which is accessible to persons in care and allows for unsupervised access to outside the building. An alarm sounds when the door is opened, and staff attend the door to ensure persons in care are not exiting the building when the alarm sounds (non-emergency events). Current monitoring of the door is up to date and sufficient, however, the lack of locking door to the exterior of the building continues to pose risk to persons in care. *This is a repeated contravention
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Routine Inspection Follow-up
5 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): One person in care's records were reviewed and there was no evidence of written agreement for restraints from the person in care's medical practitioner or their representative. On the actual restraint agreement form, there was notation of "verbal consent" for both the medical practitioner and the representative, which is insufficient under the legislation.
- 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)
- RB1.17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
- Observation(s): See "R1.10" on the inspection form for details.
- RB1.17A - Post the most recent routine inspection in a prominent place.
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The most recent routine inspection was not posted on the wall where the staff indicated it is usually posted, and was not available within the vicinity without reprinting the report.
- R1.1O - Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Two separate instances during the inspection, a key had been left in the lock of the door leading to the kitchen, which made it accessible to persons in care, and was not in compliance with the health and safety plan provided to Licensing.
- 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): One recreation care plan showed no evidence of having been reviewed since 2021.
- R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Routine Inspection
5 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Three medication administration records showed no documentation for 0800, or 1200 medications having been given. When asked, the staff in charge of administration that day confirmed the medications had been administered, but they had not yet documented the administration. This was at approximately 1pm during the inspection. Within two medication administration records, there were six missed PRN medication effectiveness documented, as per facility policy. A review of the Narcotic count records showed four missed second signatures, as is required per facility policy.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): One fire extinguisher not mounted to the wall was found in the lounge area and showed evidence of the last time it was serviced was in July 2021. All other fire extinguishers in the facility were up to date. Staff were not aware of this extinguisher being present, as it was behind a plant. No evidence available during inspection regarding self monitoring of systems from maintenance. No evidence available during inspection regarding self monitoring of systems from clinical leadership staff regarding clinical care systems.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): A review of person in care's charts showed that two persons in care did not have family or other representative listed. Staff report neither of these persons in care have family or friends available to list as a representative.
- R4.1E - Keep for each person a record showing the name and telephone number of the persons parent or representative, contact person and primary health care provider; 78( 1 )(c)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The double doors leading to the kitchen were not locked during this inspection, this allowed access to the kitchen area (with hazardous materials - sharps, cleaners etc.), through the kitchen there is also a door that leads directly outside with no alarm on the door. What systems/audits are in place to ensure persons in care are not exiting? There is a door leading from the staff cafe area to the courtyard that is kept unlocked but an alarm has been added. During the inspection this door was opened to demonstrate the alarm, but no alarm was heard. The reported practice for staff is to assess who has opened the door to ensure persons in care are not exiting the building when the alarm sounds. No staff came to assess why the door was opened and the alarm had been reset in the main area by a staff the moment it went off, per staff. Therefore the previously applied monitoring equipment and system/procedures are not sufficient. A container holding approximately 10 combs was found in the spa room, none of which were labelled to show who they belonged to, and had been used. (This was corrected during the inspection).
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- 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): Several recreation care plans were reviewed and plans were sufficient to meet the intent of the legislation, however, none of the reviewed plans were dated to show when they were initiated.
- R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
5 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Incident reporting to licensing has improved since the last licensing inspection, however licensing has not received any incident reports for aggressive/unusual behaviour. In reviewing progress notes during this inspection, behaviours were noted that had not been care planned, which were not 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)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Ensure staff are completing/charting safety checks on restraints according to the guidelines of the restraint plan. During this inspection, restraint checks had not been charted for the morning when the restraint documentation was reviewed at 12:30pm. This contravention was noted during the last routine inspection and has not been resolved.
- 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): Performance evaluations for new hires are currently behind schedule.
- R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The cafeteria room door and kitchen door were not locked during this inspection, this allowed access to the kitchen area (with hazardous materials - sharps, cleaners etc.), through the kitchen there is also a door that leads directly outside with no alarm on the door. No staff were present at this time in the kitchen area when licensing observed. What systems/audits are in place to ensure persons in care are not exiting? The doors leading from the dining area to the outside courtyard in the past have been mag locked at night to prevent persons in care from exiting, during this inspection it was learned that the mag locked is no longer in use, and at night the door lock is utilized instead of the mag lock. What systems/audits are in place to ensure persons in care are not exiting?
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- 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): Some care plans reviewed during this inspection did not contain a recreation/leisure plan.
- R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
5 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Ensure the reportable incident policy is reviewed and updated to allow for all reportable incidents noted in Schedule D of the Residential Care Regulation to be reported to Licensing immediately.
- 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 staff are completing/charting safety checks on restraints, specific to the individual PIC restraint care plans.
- 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): Weekly menu not posted at the time of this inspection.
- R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): A handwritten Medication Administration Record (MAR) was observed during this inspection. Ensure a pharmacist records all medications on the MAR.
- 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)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): There has not been a recent meeting of the Resident and Family Council. Ensure the council is re-established, and meets on a regular basis.
- R10.2S - Provide at least an annual opportunity for councils, or if no council is established, as a group, to meet with the licensee to promote the collective and individual interests of the persons in care and involve the persons in care in decision making on matters that affect their day to day living; 59(b)(i)(ii) (Show More)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
0 infractions
- Monitoring
2 infractions
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The dining area servery door was noted as open twice during this inspection with no staff present. The hot water tap on the coffee machine is accessible to PIC's when this door is unlatched. Inform licensing on what systems/audits are in place to ensure this door is keep closed to lessen the risk of a PIC accessing.
- 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): Several PIC's who have been assessed as a potential elopement risk do not have ID in place. Ensure every PIC the facility has assessed as being a potential elopement risk has ID which cannot easily be removed that indicates the PIC's name, facility name and emergency contact information. Please include in your response how the ID when in use is audited to ensure the PIC still has the ID in place.
- 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Monitoring
0 infractions
- Monitoring
3 infractions
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): The effectiveness of PRN medication is not being charted consistently, ensure med procedures are reviewed.
- Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- 10.4 Are restraint and fall prevention plans appropriate?
- Observation(s): An ongoing restraint was in place for one PIC at the facility. Ensure in the future that all restraint information and agreements are in place for all PIC's, and is available for review in the care plan.
- Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
- Provide in the care plan a plan to address, if there is agreement to the use of restraints, the type or nature of restraint and the frequency of reassessment; 81( 3 )(a)(iii)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Several benches and tables in the outdoor courtyard are dusty and require cleaning prior to resident use, several PIC's were in the outdoor courtyard during this inspection. A wire was wrapped around a fence post and gate in the the outdoor courtyard area. When the power goes out at the facility the mag-lock on this gate does not always re-attach, causing the gate to remain open, this is why the wire is in place. Please review the gate operation to ensure it functions properly without the use of the wire.
- Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
6 infractions
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Facility does not have documentation available on site to show compliance with staff credentials, ensure a process is developed (Checklist) to document staff credentials on site.
- Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
- Obtain character references for all employed persons; 37( 1 )(b)
- Obtain a record of work history for all employed persons; 37( 1 )(c)
- Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37( 1 )(d)
- Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
- 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Current posted menu does not include details of the two daily snacks available for PIC's, please update menu's to include information on daily snacks provided.
- Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
- 7.1 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 in two separate PIC washrooms during this inspection. Ensure hot water is maintained at 49 degrees Celsius at any location which is accessible to PIC's. Staining on ceiling tiles in one PIC washroom due to past water damage, Ensure ceiling tiles are replaced.
- Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- 9.1 Are medications stored, handled, and administered appropriately?
- Observation(s): Hand written changes to MAR's until new MAR's received at the beginning of the next month. Please review with Pharmacist to have new MAR sheets or stickers for MAR's available in a faster timeframe to help lessen the risk for errors.
- Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
- 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): There are several PIC's who are able to leave the building independently, ensure each PIC who is able to leave independently has ID that shows their name, facility name and emergency contact information. Ensure auditing procedures are in place to monitor if PIC has ID prior to independent outings
- Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56( 1 ) ( 2 )
- 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): Care plan information detailed in Kardex documentation at nursing station differed in on plan reviewed from the information available in PIC room. Ensure all care documentation is reviewed to ensure consistency.
- Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?