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Glenmore Lodge Community

325 Drysdale Blvd Kelowna BC V1V 1P5 · Residential Care - Licensing

7 inspections

  1. 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      • Observation(s): It is noted that one care plan contains guidance for medication that is no longer valid. Care plans that do not reflect current care needs increase the risk of staff being incorrectly guided in the provision of care, which may result in unsafe or incorrect practices and harm to persons in care. Submit to Licensing by May 25, 2026, a plan outlining how all care plans will reflect current care needs. The plan must identify the steps that will be taken to achieve compliance, as well as the measures that will be implemented to ensure ongoing compliance with legislative requirements.
      • 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)
  2. Routine Inspection

    1 infraction

    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): During the inspection, it was noted that persons in care who may leave the facility without notifying an employee and may not be capable of identifying themselves are not fitted with a bracelet or other means that cannot be easily removed.
      • R10.2M - 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) (Show More)
  3. Routine Inspection

    0 infractions

  4. Substantiated complaint

    0 infractions

  5. Routine Inspection

    3 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Staff chart restraint checks in the facility PCC data system according to the frequency of check indicated in the care plan. Hourly restraint checks observed during this inspection were often charted much later than the check occurred, 5 or 6 hours of checks charted at the same time. Ensure staff are documenting restraint checks closer to the time of the actual check.
      • 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)
    • 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 storage of person in care nail trimmers observed in one tub/spa room did not comply with facility infection control practices.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Temperature checks for the month of March 2022 in one medication fridge observed during this inspection were charted sporadically. Facility policy indicates daily checks/charting to ensure medications requiring refrigeration are kept at the optimal temperature.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
  6. Routine Inspection

    2 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): March 21, 2019 - It was noted during the inspection that the Licensee did not have a system in place to ensure that all employees had been orientated to the Residential Care Regulation. Please submit a Compliance Plan that identifies the number of employees who have not been orientated to the Residential Care Regulation, the date that the identified employees will be orientated by, and the Plan to ensure that moving forward all staff will receive the orientation. The Manager reported during the inspection that a Plan had already been put into place to educate employees to sections of the Regulation during regularly scheduled staff meetings.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): March 21, 2019 -It was noted during the inspection that the Licensee did not have a system in place to ensure that at least 2 nutritious snacks, with each snack containing at least 2 food groups are posted on the weekly menu. Please submit a Compliance Plan that will outline the system that will be put into place to ensure that snacks that are in compliance with section 62(2)(b) are posted on the weekly menu, and identify who will be responsible for monitoring to ensure ongoing compliance.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
  7. Monitoring

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): June 23, 2017 The facility has a system in place to ensure that reportable incidents are reported to Licensing. It was noted that the system was ineffective in regard to the immediate reporting to Licensing. The facility has had 50 reportable incidents since opening, and 16 (32%) were reported late.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): June 23, 2017 The facility has a system in place to ensure that person in care's records are in compliance with the regulations. The system was noted to be ineffective in regard to monthly weights. It was noted that monthly weights were missing, and documentation could not be located to indicate why the weights had not been recorded.
      • R4.1R - 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): June 23, 2017 The system for ensuring the safe storage of medications in liquid was noted to be ineffective. One medication fridge contained food in containers, and medication in liquid that was placed in the fridge in an unsealed container. This was corrected during inspection. The food items were removed from the fridge, and sealed containers will be provided to store the medication in liquid in between the time of mixing and administration. The Manager reported that education will be provided to the staff.
      • 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)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): June 23, 2017 The facility has a system in place to ensure that care is consistent with the person in care's care plan, however the system was noted to be ineffective. One person in care had been admitted to the facility one month prior to the inspection, however the Kardex posted in the room did not contain information from the care plan that would guide the staff in providing care for this person.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82