Swan Valley Lodge-30
818 Vancouver St Creston BC V0B 1G0 · Residential Care - Licensing
10 inspections
- Routine Inspection
2 infractions
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): This is an ongoing contravention. Restraint charting observed during this inspection did not reflect the frequency of monitoring as noted in the corresponding restraint care plan. Restraints must be monitored according to the restraint care plan to help ensure the health and safety of the person in care while in the restraint. Submit a corrective action plan by June 22, 2026, which indicates what systems will be put in place to ensure all restraint monitoring is completed and charted according to the 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): This is an ongoing contravention. Prescribed treatment creams observed in unlocked cabinets in some person in care washrooms. All prescribed medications/treatments must be kept inaccessible to ensure they are not accidently ingested or misused. Submit a corrective action plan by June 22, 2026, which indicates what systems will be put in place to ensure all medications/treatments are kept inaccessible to persons in care.
- R7.1AJ - Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Routine Inspection
2 infractions
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): This is an ongoing contravention. Restraint monitoring charting reviewed during this inspection. Several charts reviewed did not reflect the frequency noted in the restraint care plan. Restraint monitoring and charting must reflect the instructions noted in the restraint care plans to help prevent injury to a person in care while in a restraint. Submit an action plan by August 29, 2025, detailing what systems will be put in place to ensure restraint monitoring and charting is completed according to the instructions noted in 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): Outside activity area: Several chairs and tables observed dusty. One section of the outdoor patio observed with leaves, dirt and several cigarette butts on the ground. BBQ propane tanks observed in an area accessible to persons in care. Outdoor areas must be kept clean and free of hazards to ensure the safety and enjoyment for persons in care. Submit an action plan by August 29, 2025, detailing what systems will be put in place to ensure the outdoor areas are kept clean and free of hazards. A prescribed medicated cream was observed unlocked in a person in care room. All prescribed medications must be kept inaccessible to persons in care to help avoid medication errors or potential harm. Submit an action plan by August 29, 2025, detailing what systems will be put in place to ensure all medications are stored in a manner to keep them inaccessible to persons in care.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R7.1AJ - Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Routine Inspection
3 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): The charting of Treatment Administration Records (TAR's) was observed as inconsistently charted during this inspection. This Contravention was also noted during the last routine inspection of this site in June 2023. Since the last inspection some follow-up/auditing of the TAR's has been completed by site leadership, however the charting is still inconsistent. Please inform on what additional changes will be made to ensure TAR charting is completed.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Restraint charting was observed for the month of May 2024, some of the restraint charts did not include restraint charting for May 28th. Please inform on what systems are in place to ensure restraint checks are completed and charted as required in the individual 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)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Performance evaluations for most care staff are overdue at this time, this contravention was also noted during the last routine inspection of this site in June 2023. Two performance evaluations have been completed recently, please submit a plan on how overdue evaluations will be completed and will be kept up to date moving forward.
- R3.1N - 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)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
4 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): The charting of PRN effectiveness, as well as Treatment Administration Records was noted as inconsistent during this inspection.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Regular performance evaluations for employees are currently overdue. Ensure there is a system in place to allow for at least one staff for every shift to have valid first aid.
- 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)
- R3.1O - 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)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Posted menus do not include specific information on the two daily snacks which are provided.
- 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)
- 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): Ensure care plans for person in care who are able to leave the building independently or leave the building to smoke include specific information on steps for staff to follow to help ensure they return safely. Ensure smoking assessments are completed on a regular basis. Recreation care plans not in place for some persons in care.
- 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)
- R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
4 infractions
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): The system to ensure restraint monitoring is documented was ineffective. It was noted that restraint documentation was inconsistently completed.
- 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): The system to ensure all reportable incidents are reported to licensing was ineffective. It was noted during the inspection that some incidents had not been reported to licensing as required. Education was provided during inspection.
- 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): The system to ensure all post falls policies and procedures are followed by staff was ineffective. An updated falls assessment was noted to be missing from a chart, following a person in care having experienced multiple falls.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): It was identified that the system to ensure ongoing tray service is reassessed at least once every 30 days was not yet established. Licensee is currently developing a system to ensure documents related to tray service are easily located in a person in cares chart, as well as a system to ensure reassessment.
- 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)
- R4.3 - Is documentation concerning restraints adequate?
- Routine Inspection
3 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Treatment administration records (TARS) are not consistently recorded. Inform licensing on the audit system that will be in place to review that TARS are completed in full.
- 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): It was noted that the admission weight was missing from some of the persons in care files. It was observed that not all person in care's files included a photo.
- R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
- R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The facilities signage to identify video surveillance was not posted in the facility.
- R7.1G - Display a notice in a prominent place if electronic surveillance is being used to transmit or record images of persons in care or members of the public; 19 ( 13 )
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
4 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Treatment administration records (TARS) are not consistently recorded. Inform licensing on the audit system that will be in place to review that TARS are completed in full.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- 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): More information to instruct staff on what to do if residents who are able to leave independently do not return on time. Include in your response how this issue will be met in care plans and the system used to monitor the care plan.
- 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.
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Regular performance reviews are not up to date for all employees. Inform licensing on what plans will be in place to ensure that performance reviews are completed. Provide information on what systems will be put in place to ensure that each employee is regularly reviewed.
- 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)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): More information to instruct staff on what to do if residents who are able to leave independently do not return on time. Include in your response how this issue will be met in care plans and the system used to monitor the care plan. Oral health care plans not regularly included in the care plan summary. Licensing viewed a new template for care plan summaries that appears to meet this requirement. Inform licensing on when the new care plan template will be implemented and how it will be audited.
- 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)
- R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Licensing noted scuffing and paint chips in common hallways, doorways and resident rooms. Also noted torn drywall where soap dispensers had been removed in 2 washrooms in the common area of facility. This is a ongoing infraction since the previous inspection.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Monitoring
7 infractions
- 1 - Are all policies and procedures available to persons in care?
- Observation(s): On April 12th during inspection the RCC was unable to provide complaint process policy when requested by LO, as she indicated it was locked up in the manager's office. On April 21st when completing the inspection the Manager who had been off on leave, was able to provide the policy manual as requested. The facility has an ineffective process in place to ensure the policy manual is available to employees at all times, to licensing. and PIC and their representative.
- Ensure all policies and procedures are available to persons in care.
- 22- Is personal privacy respected and records and personal information kept confidential?
- Observation(s): Ineffective process in place to ensure the confidentiality of records of Person's in Care (PIC).
- Respect personal privacy and keep records and personal information confidential.
- 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Licensing observed non-compliance with 10 infractions for the physical environment, which is noted in the body of this report. Ineffective monitoring processes in place to maintain compliance. Manager reported a plan to put a Physical Environment monitoring process in place.
- 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): On April 12th during inspection the RCC was unable to provide complaint process policy when requested by LO, as she indicated it was locked up in the manager's office. On April 21st when completing the inspection the Manager who had been off on leave, was able to provide the policy manual as requested. The facility has an ineffective process in place to ensure the policy manual is available to employees at all times, to licensing, and PIC and their representative.
- Make all policies and procedures available to employees at all times, to licensing, a person in care and the parent/representative on request; 85( 1 )( c) (i)(ii)(ii.1)(iii)
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): Ineffective process in place to ensure the confidentiality of records of Person's in Care (PIC).
- 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
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Licensing officer observed the physical infractions listed below on 12-April-2016: -hot coffee in a glass pot on burner and close to edge of counter accessible to PIC {LO observed on April 21st that all coffee is now secured in thermal carafes. (CDI) } -hazardous cleaning agents (cavi-wipes) found on counter in multi-use area kitchen accessible to PIC. (removed and secured by RCC-(CDI) April 12/16) -prescription ointment accessible to all PIC. (removed by RCC and placed in locked med cart (CDI) April 12, 2016) -hazardous cleaning agents (cavi-wipes) found on counter in multi-use area kitchen accessible to PIC. (secured by adult day program staff (CDI) April 12/16) -found hazardous chemicals and staff personal items in unlocked recreation staff office accessible to PIC. -door secured (CDI) April 12/16. On April 21 LO discussed concern with manager and recreation staff as door was open and personal items remained accessible to PIC. Ineffective process to ensure hazardous materials are not accessible to PIC. -hazardous chemicals found on top of unsupervised housekeeping cart which is accessible to PIC. (Secured during inspection by housekeeping staff (CDI) April 12/16.) -hazardous chemicals (cavi-wipes) found in Purcell common area near courtyard accessible to PIC, (Removed and secured by RCC. (CDI) April 12/16) -key left in lock of laundry room allowing access to PIC. (CDI) April 12/16 -main courtyard: tripping hazard to PIC- uneven sidewalk near main door access, tripping hazard to PIC; behind shed variety of yard maintenance supplies; drowning hazard to PIC- large trash receptacle full of standing water; and storage shed unlocked with hazardous tools and chemicals. (CDI) April 21/16 (LO observed that all of these infractions were corrected on April 21/16.) -damaged drywall noted in public bathroom, PIC rooms, common areas and walls in hallway.
- 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)
- Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 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)
- Ensure that laundry facilities if not used by persons in care, cannot be accessed by persons in care; 35( 2 )(b)
- Ensure all medications are safely and securely stored; 69( 3 )(a)
- 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)
- 1 - Are all policies and procedures available to persons in care?
- Monitoring
7 infractions
- 2.2 Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): Two of the residents with restraints in use, did not have have the appropriate consents completed. One resident's consent form was missing the consent of the physician and the other was missing the consent of both the physician and the family or contact person.
- 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)
- 4.3 Is documentation concerning restraints adequate?
- Observation(s): Residents who had restraints in use, did not have them mentioned in their care plan summaries.
- Record the type or nature of the restraint used in the person's care plan; 84(a)
- Record the reason for the use of restraint in the person's care plan; 84(b)
- 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): Two residents were noted to be missing their TB screening and one resident was missing their immunization status. This is an OUTSTANDING contravention. (When LO returned to the office, the manager had sent a copy of one of missing TB screens).
- 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
- 10.4 Are restraint and fall prevention plans appropriate?
- Observation(s): Of the residents reviewed that were noted to have restraints in use, none of their care plan summaries reflected the type or duration for which the restraints are used.
- Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): An audit of the medication administration record (MAR) showed that the effectiveness of PRN medications are not consistently being documented.
- Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): In one pod, the door to the laundry room was propped open with a hanger. In the other pod, the door was found to be closed and locked, but the key was in the door. This is an OUTSTANDING contravention. Their were scissors found at the bedside in one of the PICs rooms. The cupboard under the kitchen sink containing powdered bleach was noted to be unlocked. One resident was noted to have prescription ointment in an unlocked cupboard in their bathroom. The medication fridge had not had a temperature recorded since August 4th.
- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- Ensure that laundry facilities if not used by persons in care, cannot be accessed by persons in care; 35( 2 )(b)
- Ensure all medications are safely and securely stored; 69( 3 )(a)
- 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): Of the charts audited, one resident's care plan was over due for review. Another resident's care plan was not dated, therefore LO was unable to ascertain if it had been reviewed. Of the medication care plans audited in the MAR, a number were noted to be overdue for review/revision with some dated as far back as 2012.
- 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)
- 2.2 Are written policies and procedures in place to guide staff in fall prevention?