River House
611 Enzo Rd Kamloops BC V2B 0E6 · Residential Care - Licensing
8 inspections
- Routine Inspection
3 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 documentation on the “Daily Hygiene Tracking Sheets” had several missed entries for multiple persons in care charts, and it could not be determined whether or not daily hygiene care had been provided. When documentation of daily hygiene care is not completed as per the Licensee’s policy, this could lead to care being missed for persons in care. Submit a written action plan to mitigate the risk of daily hygiene provision entries being missed, no later than February 6, 2026.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): The menu for the facility was reviewed and several snack entries were noted to be from one food group when the legislative standard is two food groups per snack, to be provided twice daily. When menus are not created with sufficient food groups offerings, the risk of persons in care not getting adequate nutritional needs being met is increased. Submit a written action plan of how the Licensee will ensure a minimum two food groups per snack are provided a minimum twice daily no later than February 6, 2026.
- R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Two gouges were noted in the common living room, each measuring approximately 5 cm each across and exposing drywall. When gouges and holes in walls expose drywall to persons in care, the dust and debris could be ingested by persons in care and make them ill. Submit a written action plan that will detail how the Licensee will ensure physical facility deficiencies reporting systems and maintenance systems meet legislative standards, no later than February 6, 2026.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- 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
5 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): A review of files for persons in care showed no evidence of written agreements with representatives and a medical practitioner for the restraints being used.
- 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)
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): A review of care plans showed no evidence of restraints that are currently being used were included in the plans.
- R4.3A - Record the type or nature of the restraint used in the person's care plan; 84(a)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): In two bathrooms, a "sanitization tracking sheet" had not been completed for approximately 14 days, though the facility policy is to complete the documentation daily.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R4.6 - Are facility records current and complete?
- Observation(s): A substitution list was found in the kitchen, but was not used since December 2023. Confirmation from manager that other food substitutions have occurred since that date and no documentation was able to be provided.
- R4.6C - Retain food services records of menus and menu substitutions; 87(b)
- 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 nutrition care plans were not available to be reviewed at the time of the inspection, and so there was no evidence of "assessment of nutrition status" having occurred. There was no information of specific nutrition to be provided, or mention of therapeutic diets, including altered textured diets within the plans of care, as required.
- R10.3E - Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Routine Inspection
4 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): The system to ensure that licensing is immediately notified when a person in care is involved in a reportable incident is ineffective.
- 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)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The system to ensure that the physical facility is regularly monitored is ineffective as observed by the number of contraventions for physical facility in this report.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- 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 system to ensure PRN medication effectiveness documentation is complete, as per facility policy, is ineffective. A review of PRN medication documentation identified instances where the effectiveness stated "staff left" and no effectiveness was charted.
- 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): The system to ensure that water accessible to persons in care does not exceed 49 degrees Celsius is ineffective. During an audit of the hot water temperature in the lower level kitchen the temperature read 65 degrees Celsius. *Corrected during inspection. The system to ensure that all rooms and common areas are maintained in a good state of repair is ineffective. It was observed that the lower portion of the right side door jamb of one person in care's bedroom was dented and damaged. Additionally, it was observed in the backyard that a horizontal board from a fence panel had fallen off and rusty nails were exposed. The system to ensure that all rooms and common areas are maintained in a safe and clean condition is ineffective. A watering hose was observed unwound and laying across the back patio posing a tripping hazard. *Corrected during inspection. The system to ensure that hazardous materials are stored safely and securely is ineffective. Several cans of paint were stored on the back patio and accessible to persons 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)
- R7.1J - 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
2 infractions
- 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 up to date, however the annual evaluations for longer term staff 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)
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): Ensure PIC washrooms have single use hand towels or each person in care has their own hand towel. Freezer temperatures are checked and charted daily, but a review of the last two weeks indicates the temperature noted was not within the desired range of at least minus 18 degrees Celsius.
- R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
- R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Routine Inspection
4 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 admission package reviewed during this inspection, ensure the package is updated to include information on how to express concerns to licensing.
- R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): Some PIC weights have not been monitored/recorded recently due to access to an appropriate scale during COVID, ensure a process is developed to access a scale to allow for monthly weight monitoring.
- R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Gasoline canisters and Raid bug repellant stored in the garage, ensure all potentially hazardous materials are kept inaccessible to PIC's.
- 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): Facility last held a Medication Safety Advisory Committee (MSAC) meeting in August 2019, ensure the MSAC is re-established.
- R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)
- 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
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): Facility laundry room is currently being used by some PIC's, ensure non slip surfacing is in place.
- R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): Care plan procedures are in place, but some of the care plan procedures are not documented in PIC care plans/charts. Ensure each PIC has a documented care plan which includes all requirements of RCR 81. Inform Licensing on what systems will be put in place to ensure a current written care plan is in place for all PIC's.
- R4.1Q - Ensure a care plan is developed within 30 days for persons in care admitted for more than 30 days; 81.1; Director of Licensing Standards of Practice: Advance Directives and Care Plans
- 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 procedure is to complete hourly PIC room checks overnight, a review of charting showed several nights over the past few weeks in which charting was not completed. Inform Licensing of what systems/audits will be put in place to ensure room checks are completed and charted.
- 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?
- Monitoring
2 infractions
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): One staff file reviewed indicated the first aid/CPR certificate had expired, inform Licensing on what systems/audits will be put in place to ensure all staff expiring qualifications (first aid, crim check etc) will be renewed prior to expiring.
- 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The main hallway in the upstairs portion of the home has multiple holes in the drywall and damage to one door, inform Licensing on what systems are in place to ensure damage to the home is repaired quickly. Bleach products located in the bathroom and kitchen cabinets under the sink, ensure all potentially hazardous products are stored in a manner that prevents PIC's who should not have access form gaining access. Include in your response what systems and audits are in place to ensure all potentially hazardous materials are kept inaccessible.
- 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)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Monitoring
5 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 care are able to leave the facility independently, ensure the care plan for these PIC's includes specific instructions for staff regarding the process in place to ensure PIC safety. ( How long can PIC be away? What do staff do if they do not return on time? etc...) PIC representatives should be aware of the plan and it should be reviewed during care plan reviews and as needed. Inform Licensing on what systems will be put in place to ensure care plans are updated and monitored as needed.
- 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.
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Current menu indicates a specified meal for dinner; but for lunch and breakfast the information on the menu includes options that are available. When reviewing daily meal tracking for PIC's the food eaten does not include three food groups and often includes items not mentioned in the menu choices. Ensure facility menu and meal substitution process is reviewed, inform licensing of the outcome of the review.
- R5.1C - Provide for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups described in Canada's Food Guide; 62( 2 )(a)
- R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): BBQ propane tank on the back deck was accessible at the time of this inspection, ensure the tank is stored in a manner that helps prevent easy access by PIC's.
- 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): Some PIC's in care are able to leave the facility independently, ensure there is written documentation (name, facility name, emergency contact information) in PIC's possession when they leave the facility. Please include in your response how this will be audited to ensure PIC's still have the documentation.
- R10.2L - 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 )
- 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 care are able to leave the facility independently, ensure the care plan for these PIC's includes specific instructions for staff regarding the process in place to ensure PIC safety. ( How long can PIC be away? What do staff do if they do not return on time? etc...) PIC representatives should be aware of the plan and it should be reviewed during care plan reviews and as needed. Inform Licensing on what systems will be put in place to ensure care plans are updated and monitored as needed. A behavioural care plan is required for one PIC who is a respite stay but has now been in the facility over 30 days, facility is waiting for the behavioural care plan to be developed, please indicate what documentation is in place to guide staff on behaviours while the facility waits for the plan to be developed. Ensure each PIC has a recreation plan in place that details recreation goals within the facility and while out in the community, charting should include when PIC's are meeting specified recreation goals. Ensure each PIC has a nutritional care plan in place. Inform Licensing that each PIC has a nutritional care plan and include what processes are in place to ensure the plan is reviewed on a regular basis or when required.
- 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)
- R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
- R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
- R10.3N - Develop a nutrition plan for each person in care and review the plan on a regular basis (Applies to a facility with 24 or fewer persons in care); 83( 1 )(a)( 3 )(a)
- 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?