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Felix Road

295 Felix Rd Kelowna BC V1X 6X8 · Residential Care - Licensing

8 inspections

  1. Routine Inspection

    3 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): A review of four medication administration records (MARs) showed that three of the MARs were missing initials to indicate if medication was administered as ordered. Not initialing to indicate whether a medication has been given may increase risk to persons in care's health status as a medication may be incorrectly administered. Submit by July 04, 2025, a plan detailing how MARs will be monitored to ensure medications are signed for and administered as required. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • 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): A review of four person in care charts showed that two persons in care were not being weighed monthly. Not weighing persons monthly may increase risk to persons in care's health status, as a fluctuation in weight may not be detected and could delay medical intervention if required. Submit by July 04, 2025, a plan detailing the system that will be put into place to ensure all person's weights will be documented monthly. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Observed two prescription medications left unsecured in persons in care's bathrooms. Unsecured medications may increase risk to persons in care health and safety as persons may ingest medications or incorrectly administer medications if able. Submit by July 04, 2025, a plan detailing how the storage of medications will be monitored to ensure they are not accessible to persons in care. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements. This was also a contravention in September 2023.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
  2. 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 Licensee's system to ensure checklists are completed as required was found to be ineffective. During the inspection, facility records were reviewed. One document, which indicates that the first aid supply is checked, was not completed for the months of October, November and December 2023.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.6 - Are facility records current and complete?
      • Observation(s): The Licensee's system to ensure that records are able to be retrieved in a reasonable time as requested was found to be ineffective. During the inspection, evidence of fire drills for February and March 2024 were unable to be located. Additional time was given to retrieve these documents, but the records were unable to be located in that extended time frame.
      • R4.6O - Retrieve records, other than those required to be kept in a single place, within a reasonable time if requested; 91( 2 )(b)
  3. Routine Inspection

    6 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): During the inspection, it was observed that the bathtub does not have slip resistant material on the bottom.
      • R7.2P - Ensure bathrooms have slip resistant material on the bottom of each bathtub and shower; 30(b)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The licensee's system to monitor the physical environment was found to be ineffective. During the inspection it was observed that the bathroom wall behind the door had a large hole in it. Additionally, the door on the shed in the backyard was noted to be falling apart and unsightly. Self-monitoring was noted to be in non-compliance at the previous inspection. Since then, self-monitoring has been implemented in some areas, but still remains out of compliance in other areas.
      • 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 licensee's system to ensure that the Medication Safety Advisory Committee (MSAC) policy is being followed was found to be inefficient. During the inspection it was noted that the facility has MSAC meetings, however documentation of the meetings are not being kept on file at the facility as required by the facility policy.
      • 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 licensee's system to ensure that all meals include at least 3 food groups as described in Canada's Food Guide was found to be ineffective. During the inspection, it was observed that the menus did not list specifics of meals as evidence that at least 3 food groups were included.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The licensee's system to ensure that all water accessible to a person in care does not exceed 49 degrees Celsius was found to be inefficient. During the inspection, it was noted that the water in the kitchen exceeded 49 degrees Celsius. Water temperature in the bathroom was noted to be in non-compliance at the previous inspection. This has been resolved and is now being monitored, however, there is no system to monitor the kitchen water temperature. The licensee's system to ensure that all medications are safely and securely stored was found to be ineffective. During the inspection, a prescription mouth wash was noted to be in an unlocked, bathroom cupboard. This was corrected during the inspection.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The licensee does not have a system in place to ensure that persons who temporarily leave the facility have the required written documentation, which includes their name, the name of the facility and their emergency contact information. During the inspection, it was noted that when persons leave the facility they carry identification but this identification does not include the facility name or emergency contact information.
      • 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 )
  4. Routine Inspection

    4 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): Couch located in the "den" was observed to be in a poor state of repair. Fabric is peeling off, making it very difficult to adequately sanitize.
      • R7.2N - Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): A system of self-monitoring must be implemented to ensure compliance with the Act and Residential Care Regulation (RCR) in accordance with section 61 of the RCR.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Person in care weights are not consistently being documented at least once each month as required by section 83(4)(a) of the Residential Care Regulation (RCR). Please ensure a system is in place for maintaining compliance.
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Hot water tested in shower room to be 53 degrees Celsius at time of inspection. Please ensure persons in care do not have access to water exceeding 49 degrees Celsius.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
  5. Routine Inspection

    1 infraction

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The process in place to ensure that the Medication Administration Record (MAR) is completed and signed by employees who administer routinely scheduled medications and PRNs to persons in care is ineffective. Licensing Officer reviewed two out of four persons in care's MARs and identified missing staff initials for routine medications administered and missing documentation for the effectiveness of the PRNs administered.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
  6. Monitoring

    2 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): October 30, 2017 - The facility's system for ensuring that the furniture in the facility remains in a good state of repair is ineffective. LO observed one leather arm chair that has a rip on the arm of the chair, and a second leather chair that has various worn areas on the arms, and the back of the chair. These porous areas prevent proper cleaning and sanitization of the furniture.
      • R7.2N - Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): October 30, 2017 - The system that the facility has in place to ensure compliance with the safe storage of food is ineffective. LO reviewed the fridge temperature logs for the refrigerator located in the garage. The temperature logs showed the last month and a half of recorded temperatures were between 5-9 degrees Celsius. The safe temperature for the safe storage of food is between 0-4 degrees Celsius. No corrective actions were documented. The manager stated she has not been auditing the temperature logs, and was unaware of the recorded elevated temperatures.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  7. Monitoring

    5 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): September 07, 2016 -UNRESOLVED- The facility's process to ensure compliance with providing a restraint policy that guides employees in meeting the Residential Care Regulations is ineffective. The restraint policy does not guide the staff in complying with sections 73 , 74, 75, 84 of the Residential Care Regulations.
      • Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73( 2 ); 75( 2 )(a)(i)(ii)(b)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): September 07, 2016 - The facility's process for ensuring compliance with Residential Care Regulations for restraint care plans is ineffective. The persons in care's restraint care plans do not contain the reason for the restraint, or the alternatives that were trialed.
      • Record the reason for the use of restraint in the person's care plan; 84(b)
      • Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
    • 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): September 07, 2016 - The facility's process to ensure compliance with providing a policy to ensure employees are orientated to the Residential Care Regulations (RCR) and the Community Care and Assisted Living Act (CCALA) is ineffective. The orientation policy does not contain orientation to the RCR and the CCALA
      • Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): September 12, 2016 - The facility's process for ensuring compliance with obtaining up to date Criminal Record Checks (CRC) for each employee is ineffective. Five employee files were reviewed. Two files were found to be missing a current CRC. One file for a new employee did not contain a CRC, nor was there evidence of an application for a CRC having been completed or submitted. The Licensee stated that the application for a CRC had been submitted and they were awaiting the results. The Health and Safety Plan in place is that the employee currently does not work alone. The second file reviewed contained a CRC which expired on July 07, 2016. The Manager was unaware of its expiration.
      • Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): September 07, 2016 - The facility's process for ensuring compliance with self monitoring of the physical environment is ineffective. LO noted several discoloured areas on the ceiling in the kitchen and areas where the paint is peeling. There was no documentation to show this was noted by the facility nor was there a documented plan in place to have it repaired. ON GOING - The door ways, doors, and lower walls continue to have damage as persons in care mobilize independently with electric wheelchairs. The facility manager stated that these areas are repaired several times a year however there is no documentation to show the last time the repairs were completed.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  8. Monitoring

    4 infractions

    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): March 17, 2015 - Unable to locate a TB screen with the results in resident's chart. LO did located a immunization screen that stated the Resident had been screened however unable to locate the TB screen.
      • Provide information to persons in care regarding the benefits of immunization including pneumococcal, annual influenza and tetanus-diphtheria if appropriate; 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): September 04, 2014 - UNRESOLVED - The policy for restraints is inadequate as it is missing information to guide the staff in complying with sections 73, 74,75 and 84 of the RCR. -Unable to locate the policy for release of Residents to authorized and unauthorized individuals.
      • Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85(1)(a)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): September 04, 2014 - UNRESOLVED-Staff files were reviewed and some staff files contain Serve Safe which is not a Food Safe equivalent course. Copies of any diplomas, certificates, or other evidence of staff training and skills remain missing from a staff file that was inspected. -There was a staff file inspected that had a performance review last completed in 2013. The policy states yearly.
      • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37(1)(d)
      • 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)
      • Ensure employees responsible for the preparation and delivery of food have the necessary experience, competence and training to ensure that food is safely prepared and handled, and meets the nutrition needs of persons in care; 44 (1)(a)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): September 04, 2014 - UNRESOLVED - The doors and door frames in the home remain heavily damaged and requiring repair and paint.
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)