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Rose Wood Village

8125 Devito Dr Trail BC V1R 4X9 · Residential Care - Licensing

13 inspections

  1. Substantiated complaint

    1 infraction

    • 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): Allegation: The Licensee is in non-compliance with section 60(c) as it pertains to allegations of the Licensee not responding promptly to concerns. During the Family Resident Council in March of 2025, a concern was raised about the resident bus being non operational. As of March 9, 2026, the complainants had not received a response. Findings: The Licensee confirmed that it was not known what the plan was for the bus at the time the concern was received. The Licensee drafted a memo in October 2025, explaining that the bus would be retired and that alternative arrangements are available for resident outings. However, the memo was not disseminated until March of 2026. This complaint is SUBSTANTIATED. Licensees must have a process in place to ensure all concerns are addressed promptly as this works towards supporting the health, safety, and dignity of persons in care. Please provide a written response by April 24, 2026, which will outline how you will ensure that concerns will be addressed promptly. The plan must also detail the system you will use to monitor the implementation of the plan, thereby ensuring sustained compliance moving forward.
      • R2.1L - Respond to all complaints, concerns, disputes promptly. 60(c)
  2. Routine Inspection

    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 system for ensuring care plans are updated with current care needs is ineffective. Two persons in care were noted to have bed alarms in place in their rooms, however, these interventions were not outlined in the persons in care’s care plans. Incomplete fall care plans may increase a person in care's risk of falls and injuries, as employees may not consistently implement all fall interventions in place. Submit by July 3, 2025, a written plan confirming that the two care plans identified have been updated. The plan must also detail how you will ensure that all interventions being utilized for persons in care are outlined in all persons in care's care plans. The plan must include the system you will implement to support ongoing monitoring to ensure sustained compliance.
      • 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)
  3. 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): The system for ensuring that policies are implemented by employees appeared to be ineffective. Licensing noted that the process for identifying persons in care with aggressive behaviours was not being followed. A person in care had a care plan in place for behaviours, however an identifier was missing on the person in care's chart.
      • 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): The system for ensuring that all required staff have valid first aid appeared to be ineffective. In a review of staff files, licensing noted a staff member working on a casual basis did not have a valid first aid certificate on file.
      • R3.1R - 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)
  4. 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 audit tools developed to ensure monitoring measures are in place were not being completed.
      • 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 emergency plan was recently reviewed in March of 2023, however, there was some outdated information noted due to staffing changes since that time.
      • R2.1H - Update emergency plans if there is any change in the facility; 51 ( 2 )
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system to ensure that performance reviews are conducted as per section 40 of the RCR was noted to be ineffective. This is an outstanding contravention from January 11, 2023. An action plan is pending.
      • 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)
  5. Substantiated complaint

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The complainant expressed concerns with the licensee's oversight of employee performance. During the review into this concern, Licensing noted that performance reviews were not being conducted as required and therefore, this complaint was found to be substantiated. RCR section 40(1) was noted to be out of compliance at the last routine inspection conducted January 11, 2023 and therefore this is now an outstanding contravention.
      • 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)
  6. Substantiated complaint

    1 infraction

    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The complainant expressed concern regarding the care and monitoring of a resident. Licensing reviewed documentation, facility records, staff statements, and held discussions with the licensee. Licensing noted that care had been provided, supervision was in place; however, there was inadequate documentation for ongoing assessments. Therefore, this complaint was found to be substantiated.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  7. Routine Inspection

    3 infractions

    • RB1.25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): See R.4.1 above.
      • RB1.25A - Ensure care plans are developed within 30 days.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): In reviewing the system for ensuring staff files contain all requirements, the licensee acknowledged that there are small amount of staff without a current CRC on file. Licensing requested an immediate plan to address this issue which was received and accepted prior to the generation of this report. The current system in place to ensure that employees have their performance reviewed regularly appeared to be ineffective. The system in place to ensure staff are trained in emergency drills appeared to be ineffective. The licensee had not conducted a fire drill within the past three months.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • 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)
      • R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system for ensuring that all residents have a care plan developed within 30 days of admission appeared to be ineffective. An admission from October 2022 was noted to have an incomplete care plan.
      • 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
  8. Substantiated complaint

    1 infraction

    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The complainant expressed concerns relating to a resident not receiving adequate assistance to set up for meals in their room. Licensing noted lack of documentation in relation to this allegation. The resident's care plan did not indicate that they take meals in their room, nor was there evidence of approval/review by medical practitioner/dietician. In review of this information with the licensee, licensing learned that corrective actions had been initiated to address this non-compliance.
      • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
  9. Routine Inspection

    7 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): The system to ensure written agreements are in place by the person in cares representatives was ineffective. It was noted that consent from the medical practitioner was received and up to date.
      • 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): Upon a review of restraint monitoring documents, it was noted that the system to ensure consistent monitoring of restraints was ineffective.
      • 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)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Upon a random audit of charts it was noted that multiple fall prevention plans did not contain a plan for preventing the person in care from falling. It was also noted that not all charts contained a current falls assessment.
      • R10.4P - Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (Show More)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Of the charts reviewed it was identified that the system to regularly monitor the care and services provided was ineffective. This was noted by some resident care flow sheets being inconsistent in completion, missing person search forms being incomplete, as well as inconsistent skin observation tools being used which contained differing information.
      • 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): Of the charts reviewed it was identified that the system to ensure policies are implemented by staff was ineffective. This was noted on reviewed Skin Observation Tools, that were missing sign off from nurses as per the policy and process. It was also identified that staff were not signing and dating behavioral care plans as required. The licensee informed Licensing that they will be reviewing the behavioral care plan signing requirement, and making changes accordingly.
      • 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): The system to ensure all staff ensure persons in care records are kept confidential was ineffective. It was noted that the cabinet containing records was unlocked at the time the Licensing Officer was inspecting the physical site. This contravention was corrected during inspection. The Director of Care provided immediate education to the regional staff member identified in leaving the records unlocked.
      • R4.1S - Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • 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): Of the charts reviewed it was identified that the system to ensure oral care plans are included was ineffective. It was noted that there was no indication of each person in cares specific needs related to oral care.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  10. Routine Inspection

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system in place to ensure that performance reviews are conducted regularly appeared to be ineffective. In a review of staff records, some staff have not had one and some had not had one since 2014-2017. It was noted that three staff have had performance reviews this month. The current system in place to ensure staff are trained in emergency plans appeared to be ineffective. In a review of records, licensing noted that the last time a drill was conducted was June 2020.
      • 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)
      • R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
  11. Monitoring

    3 infractions

    • RB1.25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): In a random audit of care plans, LO noted that not all resident's have an oral care plan in place.
      • RB1.25B - Ensure care plans include all required elements.
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system for ensuring all hazardous items are safely and securely stored appeared ineffective. LO noted in one cottage that Cavi wipes and Lysol wipes were 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): In a random audit of care plans, LO noted that not all resident's have an oral care plan in place.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  12. Monitoring

    3 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The auditing system used to ensure resident records maintain clear and update date immunization statuses for all PICs appears to have broken-down. Of the charts audited, none contained information around immunization status beyond influenza. This is an outstanding infraction. Please notify licensing of the system you will utilize to ensure all resident records have clear and up to date immunization statuses.
      • R6.2B - Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 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 for ensuring all policies and procedures are reviewed/revised, at minimum annually, appears to be ineffective. LO reviewed the policy and procedure manual in the nurses station and noted the Fall Prevention policy and Wandering/Missing person policy had last been reviewed in 2015. LO reviewed the policy and procedure website which indicated the same dates for those policies. Please inform licensing of the system you will use moving forward to ensure policies are reviewed/revised, at minimum, annually.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system used to ensure that fridges in resident rooms are monitored to ensure that food is safely prepared and stored is ineffective. During the physical walk-through, LO noted 3 fridges without monitoring sheets in place. (see closing comments).
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  13. Monitoring

    5 infractions

    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Upon a random chart audit, LO could not locate a TB screening or immunization status for a resident.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 (1)
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 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): The evacuation site was not listed in the Emergency Response binder.
      • 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): The licensee was able to produce a staffing spread sheet which was not completed. LO verified through the staff files that criminal record checks and first aid were completed, however, due to time constraints other requirements could not be verified.
      • 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)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Upon a random chart audit, LO noted a resident admitted two months previous did not had a record of their height and weight on admission.
      • Record the height and weight of each person in care on admission; 49 (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): Not all residents had a medication care plan in place. The care plans in place were not dated and therefore LO was unable to ascertain if they had been reviewed. Oral care plans were in place but contained minimal information. There was no direction to guide staff as to the frequency of care and what type of care was required. Upon a random Care Plan audit, the recreation care plans were not "individualized". There was a brief note on the "My Day" form indicating whether or not the resident liked activities but it did not speak to what activities the resident enjoyed.
      • Care plans must include a plan to address medication, including self-medication; 81(3)(a)(i)
      • Care plans must includes an oral health care plan; 81(3)(b)
      • Care plans must include a recreation and leisure plan; 81(3)(d)
      • 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)