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Westsyde Care Annex

2980 Westsyde Rd Kamloops BC V2B 7E9 · Residential Care - Licensing

9 inspections

  1. Routine Inspection

    1 infraction

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The posted menu in the kitchen did not include information on what daily snacks are provided to persons in care. The system to ensure that snacks contain at least two food groups is ineffective. Not meeting minimum nutritional requirements may pose health risks. Submit a corrective action plan by November 14, 2025, which indicates how the facility will ensure persons in care will be offered at least two daily snacks which include at least 2 food groups.
      • 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)
  2. Routine Inspection

    1 infraction

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The auditing system in place for the medication fridge in the medication room was inadequate, daily charting of temp audits were outside the range of optimal storage temperature for refrigerated medications.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
  3. Routine Inspection

    2 infractions

    • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): Due to a vacant recreation worker, the recreation activities available within the facility over the past few months has been minimal. Please inform on what steps will be taken to increase recreation activities until such time the recreation role is filled.
      • 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)
    • 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 care plans reviewed did not include an oral care plan.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  4. Routine Inspection

    7 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Restraint plans in place did not include specific instructions for staff on how often the restraint needed to be monitored when in use.
      • R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Most recent routine inspection not posted at the time of this inspection.
      • R1.1O - 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)
    • RB1.17 - 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): Most recent routine inspection not posted at the time of this inspection.
      • RB1.17A - Post the most recent routine inspection in a prominent place.
    • 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 has a complaint/dispute resolution process, ensure the process is updated to include Licensing Direct contact information. This contravention was noted during the last routine inspection and was found unresolved during this visit.
      • R2.1J - Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(a)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Criminal record reviews were completed for each staff, however some were completed through the RCMP instead of the Criminal Record Review Program which is required. Ensure all staff receive clearance through the Criminal Record Review Program.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): During this inspection a handwritten medication administration record (MAR) was observed, ensure all MAR's are completed by the Pharmacist.
      • 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)
    • 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 review of person in care (PIC) monthly weight records, one record indicated a significant weight loss over one month, no follow-up was completed. In follow-up during this inspection it was learned that the weight loss was due to scale error. Inform Licensing on what processes will be put in place to ensure follow-up is completed when PIC weight changes are noted.
      • R10.3R - Seek immediate advice from a health care provider if a person in care has experienced unintentional and significant change in weight; 83( 4 )(b)
  5. 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): PIC's who are able to leave the building independently do have care plans in place that speak to some steps to take if they do not return by the specified return time, ensure the plans are reviewed/updated to include specific details for each PIC who can leave independently. Recreation plans are in place for each PIC, ensure facility charting includes more detail on how/when these recreation goals are being met.
      • 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)
  6. Routine Inspection

    2 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): It was noted that there was no monitoring of the use of restraint on one person in care while in wheelchair with lap belt. There is no restraint care plan for one person in care in regards to the use of a lap belt restraint while in wheelchair.
      • 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)
      • R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It was noted that some light fixtures in a bedroom and two bathrooms were missing light covers, as well as some bathroom fans were observed as dusty. The snow was not removed from the deck and staircase leading from the emergency exit from the upstairs bedroom in the Annex.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
  7. Monitoring

    2 infractions

    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Fridge and freezer monitoring systems are in place, daily auditing is occurring, but the optimal zones for temperatures are noted on the tracking document in Celsius and several thermometers in use at the facility are in Fahrenheit. Some of the Fahrenheit temperatures reviewed were out of the optimal food storage zone. Please review food temperature auditing procedures to ensure food is always stored at the appropriate temperature in facility fridges and freezers. Flu season signage and masks not available at the entry door to the facility, inform licensing that this has been rectified, also inform licensing on what systems will be put in place to ensure flu season preparations occur every year from December 1 to March 31. Documentation regarding which staff have received a flu shot and which need to wear a mask is in place.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
      • R6.3F - Develop general facility outbreak prevention and control policies as recommended by the medical health officer; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 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 behavioural care plans reviewed lacked specific details for staff indicating how they should attempt to achieve the direction given in the plan. Inform Licensing on how all behavioural plans will be updated, also inform licensing on what procedures are in place to ensure care plans are audited on a regular basis.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
  8. 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): PIC file reviewed for a respite client did not include a complete care plan, Licensing met with the facility manager to discuss the missing information. Inform Licensing that the care plan has been updated, also inform Licensing on what systems are in place for new admissions to ensure care plans are completed.
      • 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.
    • R10.1 - Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): PIC file reviewed for a respite client did not include a complete care plan, Licensing met with the facility manager to discuss the missing information. Inform Licensing that the care plan has been updated, also inform Licensing on what systems are in place for new admissions to ensure care plans are completed.
      • R10.1G - Ensure the screening processes considers the needs of the person, including any needs identified specifically in a care plan; 47( 2 )(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): PIC file reviewed for a respite client did not include a complete care plan, Licensing met with the facility manager to discuss the missing information. Inform Licensing that the care plan has been updated, also inform Licensing on what systems are in place for new admissions to ensure care plans are completed. PIC chart reviewed included significant weight change from one month to the next, no information available in the file regarding what steps were taken to follow-up, inform licensing on what systems are in place when a significant weight change is noted while weighing PIC's.
      • 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)
      • R10.3R - Seek immediate advice from a health care provider if a person in care has experienced unintentional and significant change in weight; 83( 4 )(b)
  9. Monitoring

    3 infractions

    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): One care plan reviewed included multiple missing months in 2015 for weight monitoring. Ensure each PIC is weighed at least monthly (or according to nutritional care plan) and this information is reviewed to determine if any actions are required due to significant weight loss or gain.
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The lower portion of walls in hallways, bathrooms and doorways throughout one half of the building is in need of repair (patch and paint). This was noted for the whole building during the last inspection, at this point half of the building has been completed and preparations are in place to complete the other half. Inform licensing in writing on when this will be completed.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Several PIC's are able to leave the building independently, ensure each PIC who is able to leave independently has documentation in their possession which includes their name, facility name and emergency contact information.
      • 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 )