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Ridgeview Lodge Community

920 Desmond St Kamloops BC V2B 5K6 · Residential Care - Licensing

10 inspections

  1. Routine Inspection

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): In one staff file there was no current criminal record check found. Once discovered, an immediate Health and Safety Plan was submitted to Licensing and implemented to mitigate the risk. When staff have not completed a criminal record check, this increases risk that people with a criminal record could have access to persons in care, who are vulnerable. Submit a detailed corrective plan of how you will ensure all staff employed at the facility have a current and valid criminal record check on file, no later than July 22, 2025.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
  2. Routine Inspection

    0 infractions

  3. Routine Inspection

    4 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): The system to ensure that there is an agreement to the use of a restraint given in writing is ineffective. It was observed during inspection that a restraint was implemented for one person in care without an agreement given in writing by the designated parties.
      • 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)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system to ensure that a medical health officer, in the form and the manner required by the medical health officer, is immediately notified if a person in care is involved in a reportable incident is ineffective. Several incident reports, with incidents occurring on weekends, have not been received until the next business day following the weekend. *This is an ongoing contravention.
      • 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): The system to ensure that a restraint is not used unless the safety and physical and emotional dignity of the person in care is monitored throughout the use of the restraint is ineffective. It was observed that, for two persons in care, restraint check documentation was incomplete.
      • R10.4C - Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system to ensure that water accessible to persons in care does not exceed 49 degrees Celsius is ineffective. During a random audit of hot water temperatures, at one sink on the first floor, the temperature read 63.6 degrees Celsius. *Corrected during inspection. *This is an ongoing contravention. The system to ensure that all rooms and common areas are maintained in a good state of repair is ineffective. It was observed that in two areas on the concrete pathway, in the outdoor courtyard, pose a tripping hazard. The system to ensure that secure, safe and adequate storage areas for cleaning agents and other hazardous materials is ineffective. It was observed that in two locations cleaner wipes were accessible to persons in care, and a shaving razor was located in an unlocked cabinet and accessible to persons in care. *Shaving razor corrected during inspection. The system to ensure that all medications in the community care facility are safely and securely stored is ineffective. It was observed that a prescription treatment cream was located on a bathroom counter and accessible to person in care. *Corrected during inspection.
      • 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)
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
  4. Routine Inspection

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Facility incident reports have in general been received complete since the last routine inspection, however some incident report have not been received immediately. Some incident reports have not been received for 2-3 days after the incident.
      • 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)
    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Facility policy indicates care plan/Kardex documentation will be kept in facility Point Click Care data system and not posted in person in care bathrooms, in one room checked during this inspection an outdated care plan/Kardex was observed to be posted in a bathroom. Facility policy indicates housekeeping audits including bedroom/bathroom and neighbourhood checks will be completed and charted regularly, during this inspection it was indicated the audits have been completed, however the documentation of the audits was not available for review.
      • 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): A medicated cream was located on the counter in a PIC bathroom during this inspection.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Ensure all PIC's who have been assessed as potentially exiting the facility without notifying staff, and may not be capable of identifying themselves have some type of ID indicating their name, facility name and emergency contact information.
      • 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)
  5. Routine Inspection

    5 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Required monitoring checks for restraints are being documented in the facility charting system, some of the checks are being entered much later (4 hrs) after the checks were completed. Establish expectations regarding the timeframes for charting after the checks are completed, as well as a regular auditing system to ensure compliance by staff.
      • 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): Regular performance reviews for long term staff are on track, but probation reviews for newer staff have fallen behind. Inform Licensing on what steps will be taken to ensure staff reviews are kept up to date.
      • 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): Ensure there is a system in place to check water temperatures in areas accessible to PIC's to confirm the temperature does not exceed 49 degrees Celsius.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Due to COVID 19, regular in person Family and Resident Council meetings have been cancelled. Inform licensing on what steps will be taken to reestablish the Council virtually or through teleconference moving forward.
      • 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)
    • R10.3 - 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 newer admission (2-3 months) care plans were reviewed during this inspection and were found to have incomplete recreation plans, inform Licensing on what steps will be taken to ensure recreation plans are completed on schedule.
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
  6. Routine Inspection

    4 infractions

    • RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
      • Observation(s): Some PIC's in the facility are able to leave the building independently, ensure each PIC who can leave independently has a care plan in place that details the specifics of their individual plan (How long are they able to leave? What steps do staff take if they are late returning? Does the PIC carry a cell phone? ID in place? etc..).
      • RB1.23A - Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
    • 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 Kardex documents in PIC rooms must be reviewed/update every three months, some of the documents reviewed during this inspection were noted to be beyond the three month guideline.
      • 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): Facility auditing/tracking procedures for staff who hold a valid first aid/CPR certificate are inadequate, inform Licensing on what systems will be put in place to ensure all staff who require first aid/CPR will have a valid certificate.
      • 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)
    • R10.3 - 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 PIC's in the facility are able to leave the building independently, ensure each PIC who can leave independently has a care plan in place that details the specifics of their individual plan (How long are they able to leave? What steps do staff take if they are late returning? Does the PIC carry a cell phone? ID in place? etc..). Monitoring procedures to ensure PIC's receive baths on their regular schedule is not in place, the facility is currently working on a procedure due to recent issues with bath delivery. Ensure the process includes information on when an incident report would be required due to a missed bath.
      • 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)
      • 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
  7. Monitoring

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Licensing incident report tracking systems indicate several IR's received by Licensing since the last inspection have been received late. Incident reporting procedures discussed with the facility manager and DOC during this inspection. Inform Licensing on how the facility IR procedures will be updated/audited to ensure Licensing receives all IR's within one business day.
      • 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Performance evaluations for new staff are currently behind schedule as well as some regular reviews for longer term staff. Inform Licensing on what systems will be put in place to ensure staff performance reviews are completed on 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Some PIC's who have been assessed as an elopement risk do not have ID in place. Inform Licensing on what systems will be put in place to ensure PIC's who have been assessed as a potential elopement risk will have 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)
    • 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 indicates PIC's each have a review of their care plan monthly, after this review the Kardex in the PIC bedroom is updated and reprinted to indicate the date of the review. In one section of the building, several of the Kardex documents reviewed during this inspection had not be updated/printed since May 2018. Inform Licensing on what systems/audits are in place to ensure the procedure of reviewing care plans monthly and updating documents is completed.
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
  8. Monitoring

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): A reportable incident was discussed during this inspection which had not yet been reported to Licensing although it had occurred 5 days earlier, the representative for the PIC involved was not notified until 3 days after the incident. Inform Licensing on what follow-up will be conducted regarding this incident as well as what systems/audits will be put in place to ensure all reportable incidents are reported to PIC representatives, medical, funding and licensing immediately.
      • R4.5B - Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77( 2 )(a)
      • R4.5C - Immediately notify the medical or nurse practitioner responsible for the person in care involved in a reportable incident; 77( 2 )(b)
      • 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)
      • R4.5E - Immediately notify the funding program, if any, if a person in care is involved in a reportable incident; 77( 2 )(d)
    • 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 an evacuation plan that included two locations (one nearby the facility, the other was out of the direct neighbourhood in case the emergency required a further distance), the location which was out of the neighbourhood is no longer available for use. Please update you emergency evacuation procedures to include any changes. Include in your response how often emergency evacuation procedures are reviewed and how staff are made aware of any changes.
      • 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The current facility Food Service Manager is not a member of the Canadian Society of Nutrition Management, inform Licensing on what steps will be taken to rectify this issue. This was noted and resolved previously as an infraction at this facility in June 2014.
      • R3.1S - The food services manager must be either a nutrition manager with membership in the Canadian Society of Nutrition Management (CSNM), a person eligible for membership with the CSNM, or a dietician (Applies to 50 or more persons in care); 44( 2 )(a)(b)(c)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Staff purses and backpacks stored in areas which are accessible to PIC's. Staff bags may contain items which are potentially hazardous to PIC's (lighters, medications etc). Inform Licensing on where staff will be able to store personal belongings to ensure they are not accessible to PIC' s, also include in your response how this will be audited to ensure compliance.
      • 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): A behavioural care plan reviewed today did not include information regarding triggers and redirection techniques specific to the PIC involved. Inform Licensing that this behavioural plan has been updated, also include in your response information on how all behavioural care plans are developed and audited to ensure they are complete and up to date.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
  9. Monitoring

    3 infractions

    • RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
      • Observation(s): Several PIC's are able to leave the building independently, ensure care plans for PIC's who can leave independently include details specific to the person in care (how long they are able to leave for? what are staff to do if they do not return by specified the time? sign in and out procedures, etc...) these plans should be developed in conjunction with PIC's representatives, the plans should be reviewed at least annually or if changes are required. Inform Licensing on how these procedures will be added and on what systems will be in place to audit the procedures.
      • RB1.23A - Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Two PIC's who have been identified as elopement risks did not have ID on at the time of this inspection, this infraction was noted on the last Licensing inspection. Inform Licensing that the ID is in place for all PIC's who the facility has identified as an elopement risk, also inform Licensing on how the ID for PIC's who have been identified as an elopement risk will be audited on a regular basis to ensure it is still 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)
    • 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 PIC's are able to leave the building independently, ensure care plans for PIC's who can leave independently include details specific to the person in care (how long they are able to leave for? what are staff to do if they do not return by specified the time? sign in and out procedures, etc...) these plans should be developed in conjunction with PIC's representatives, the plans should be reviewed at least annually or if changes are required. Inform Licensing on how these procedures will be added and on what systems will be in place to audit the procedures.
      • 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)
  10. Monitoring

    7 infractions

    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Manager name not displayed at the time of this inspection, ensure facility manager name is posted in the facility. Pleases develop a self monitoring review system for compliance with the residential Care Regulation. Ensure documentation of reviews are available for review by licensing upon request.
      • Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
      • Regularly monitor the physical environment and the care and services provided; 61
    • 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): Ensure the facility emergency evacuation plan including procedures for transfer to an alternate location are reviewed and all key staff are aware of the procedure. Ensure the emergency evacuation plan is reviewed at least annually and staff are notified of any changes.
      • Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Facility policy is to ensure performance reviews are conducted every two years for all staff, some staff are currently overdue for a regular performance review. Inform Licensing of the plan to have all overdue evaluations completed.
      • 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)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Several fridges in Leisure centres throughout the building did not have thermometers to ensure appropriate temperature, one fridge observed to contain outdated food. Ensure a monitoring system is in place for all food storage areas to ensure temperature and best before dates for food are appropriate.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): One soiled utility room door was not latching properly at the time of inspection allowing potential access to the room by PIC's. Cleaners and other potentially hazardous materials stored in this room. Doors propped open in one staff area at the time of inspection, no staff were present, staff belongings stored in this room, two fridges in this room, ensure this are is locked when staff are not present to prevent PIC's from accessing. Cleaner found under the sink in leisure room, ensure all cleaners are kept inaccessible to PIC's.
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Several PIC's who have been identified as an elopement risk do not currently have identification.
      • 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)
    • 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): One PIC care plan reviewed and discussed with the facility manager, a behavioural care plan is required and is not currently in place. Ensure a behavioural care plan is developed in consultation with PIC representatives.
      • Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)