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Slocan Community Health Centre

401 Galena Ave New Denver BC V0G 1S0 · Residential Care - Licensing

7 inspections

  1. Routine Inspection

    3 infractions

    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): R4.1U - In review of monthly weight records it is noted that multiple persons in care do not have weights recorded, or documented as refused, consistently each month. Failure to complete and document monthly weights creates a risk that changes in health status and nutritional needs are may not be identified, monitored, or responded to appropriately, potentially impacting the health and well-being of persons in care. Submit by July 30, 2026, a written plan outlining how the contravention related to monthly documentation of weights, or refusals has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 83(4)(c) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): R10.2V - In review of person in cares charts it is identified that ongoing tray service is captured on care plans. There is no documented evidence available at the time of the inspection to indicate that persons in care receiving ongoing tray service are reassessed at least every 30 days by either the medical practitioner, nurse practitioner, or Dietician. Failure to regularly reassess tray service may result in care practices no longer reflecting a person in care's current needs, abilities, and preferences. Submit by July 30, 2026, a written plan outlining how the contravention related to ongoing tray service reassessments at least every 30 days has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 63(3)(c)(iv) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • 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 practitioner, nurse practitioner, or Dietitian; 63( 3 )(c)(i)(ii)(iii)(iv) (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): R10.3D - In review of oral care plans it is noted that the only information captured is whether persons in care have dentures, their own teeth or no teeth. The care plans do not include the level of support of type of assistance required. The absence of clear direction for oral care leads to increase risk of poor oral health. Submit by July 30, 2026, a written plan outlining how the contravention related to oral health care plans has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 81(3)(b) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  2. Routine Inspection

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system to ensure that a medication administration record showing the date, amount and time at which the medication was administered is ineffective. On review of medication administration records, standing order medications were handwritten in the MAR and did not denote the required elements.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(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?
      • Observation(s): The system to ensure that policies are implemented by employees is ineffective. On review of bowel monitoring documentation, it was observed that documentation was incomplete for several persons in care, contrary to facility policy.
      • 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 to ensure that all employees comply with the policies and procedures of the medication safety advisory committee is ineffective. A review of medication administration records identified several instances where PRN (as needed) medication effectiveness was not documented. Furthermore, inconsistent documentation of PRN medication was identified within the medication administration records and nurses' PRN notes.
      • 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): The system to ensure that all rooms and common areas are maintained in a good state of repair is inefficient. It was observed that there was peeling paint and dents to walls, and the finish was wearing off on wooden fixtures such as doors and cupboard doors.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  3. Routine Inspection

    5 infractions

    • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): There is currently no official planned recreation at the facility.
      • R8.1A - Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55( 1 )(a)(i)
    • R8.2 - Does the program of activities support individualized care plan requirements?
      • Observation(s): There is no official planned recreation occurring at the facility, therefore the licensee is unable to meet the objectives of the persons care plan.
      • R8.2A - Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55( 1 )(a)(ii)
    • RB1.13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): See R 8.1, R 8.2 and R 10.3 above.
      • RB1.13A - Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the 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): The behavioral alert process was not consistently being followed. During the inspection, licensing noted some alerts were posted where they were not needed, and where some alerts were needed, they were not posted. The licensee was noted to not have followed the incident reporting process in relation to one incident. An incident report had been received for a service delivery problem. Licensing had requested a Health and Safety Plan prior to the initiation of any repairs. The health and safety plan was not received as requested. This was corrected during the inspection.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • 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 that all residents have a recreation care plan in place appeared to be ineffective. In a review of facility records, licensing noted that only some residents had a recreation care plan in place.
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
  4. Monitoring

    3 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): In review of the treatment records in the RCA binder, it was noted that some treatments (medications) which were ordered to be given twice per day were not consistently documented as being given. One record reflected that one resident had 14 empty boxes where there was no documentation.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system for ensuring that all requirements on admission are complete per section 49 of the RCR appeared to be ineffective. In a random audit of staff files, a number of charts did not contain the resident's height and weight upon admission.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): LO noted cough syrup, and some medicated creams were not labelled by the pharmacy.
      • 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)
  5. Monitoring

    5 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): LO informed the DOC that there were no incidents reported for Fall or Unexpected Illness in the past year. The DOC agreed that that is very unlikely that no residents were injured by a fall or sent to hospital/or received emergency medical treatment.
      • 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)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): In a random audit of resident records, LO noted that the admission screening process/ chart audit process is missing the immunization status of persons in care beyond flu and pneumococcal.
      • 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
    • RB1.25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): See number 24 above. The system for ensuring medication care plans are created/updated/reviewed is ineffective. The system for ensuring fall care plan information is current, reviewed, revised, at minimum annually, is ineffective.
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): There is a system in place to monitor the physical facility, as evidenced by a list of items requiring attention in the director of care's office. However, numerous items on the list needing repair have been on the list for an extended period of time. This is an OUTSTANDING contravention.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(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): The process for creating/updating/reviewing medication care plans is ineffective. The current system in place consists of the medication care plan written on post-it-notes which are not dated. LO was unable to determine when they were created or last reviewed. One resident had three post-it-notes with three different methods to take medications. The system for ensuring that falls care plans are updated/reviewed at minimum annually appears to be ineffective as evidenced by the Fall Precautions form noted in residents' bathrooms. Of the forms reviewed, LO noted that two were not dated, one was dated in 2014 and the other had a date of March 2016.
      • 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)
  6. Monitoring

    15 infractions

    • 8.1 Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Licensing observed that there is no monitoring and tracking process in place to ensure that PIC are actively encourage to participate in program of activities provided.
      • Encourage persons in care to participate in the program of activities provided (Does not apply to Hospice); 55( 1 )(b)(i)
      • Encourage persons in care to take advantage of physical, social and recreation opportunities available in the community (Does not apply to Hospice); 55( 1 )(b)(ii)
    • 15 - Are persons in care encouraged to participate in the facility's program of activities and to take advantage of opportunities available in the community?
      • Observation(s): Licensing observed that there is no monitoring and tracking process in place to ensure that PIC are actively encourage to participate in program of activities provided.
    • 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): Licensing observed that the most recent inspection was not posted.
      • Post the most recent routine inspection in a prominent place.
    • 22- Is personal privacy respected and records and personal information kept confidential?
      • Observation(s): Licensing observed that the room that the PIC's charts are kept was left open, allowing access to private and confidential information to PIC, family, and visitors.
      • Respect personal privacy and keep records and personal information confidential.
    • 25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
      • Observation(s): Care Plan review noted: Process in place is ineffective to identify and ensure the persons at risk of leaving the facility are identified and an elopement care plan is implemented.
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): There has been a change in manager and Patient Care Coordinator since the previous inspection which licensing was not notified. Licensing observed that the most recent inspection was not posted. Licensing observed that there is an ineffective process in place to monitor the physical environment and the care and services provided as discussed in the report below. Physical environment - uneven sidewalk. Care- - elopement care plans. services - auditing tools for dietary.
      • Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
      • 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)
      • 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): Licensing observed that there is inconsistent monitoring and documenting of fire drills.
      • 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): Licensing observed the Medication Administration Record found inadequate responses to prn effectiveness according to the medication safety and advisory committee.
      • Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing observed that the room that the PIC's charts are kept was left open, allowing access to private and confidential information to PIC, family, and visitors.
      • 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
    • 4.6 Are facility records current and complete?
      • Observation(s): Licensing observed that there is no recent documentation of food audits. There is an ineffective process in place to monitor food services and nutrition care.
      • Retain the results of monitoring of food services and nutrition care; 87(c)
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Licensing observed that there was no documented record of substitutions from the menu.
      • Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing observed uneven sidewalk transitions in the locked courtyard area near lake. This is a safety hazard for PIC. Licensing observed that the utility room door was left open allowing access to Person's in Care (PIC) to hazardous chemicals. (CDI)
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): Licensing observed that there is no record of MSAC meetings since previous inspection.
      • 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)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Licensing observed that there is an ineffective system in place to ensure that PIC who leave the facility unannounced have written documentation or an ID bracelet to provide information about PIC if they could not identify themselves.
      • 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 )
      • 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): Care Plan review noted: Process in place is ineffective to identify and ensure the persons at risk of leaving the facility are identified and an elopement care plan is implemented.
      • Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
  7. Monitoring

    4 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Upon a random audit of treatment administration records (TARs), it was evident some treatments are not being signed for.
      • Keep a medication administration record showing all medications administered to the person in care; 78(2)(a)
    • 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): In the "administrative binder" there was a complaint policy dated 2011. In the chart room, LO noted a "missing resident binder" with a policy dated 2006. In the care plan binder, a restraint policy was noted to be "site specific" to the Kelowna General Hospital.
      • Review and, if necessary, revise policies and procedures at least once a year; 85(1)(b)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The door to the hair salon was locked but able to be pushed open. The door to the cleaning supplies room adjacent to the hair salon was open.
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35(1)(c)
    • 10.3 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 medication care plans in the medication administration record (MAR) were complete, however, they were not dated and therefore LO was unable to determine if they had been recently reviewed.
      • 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)