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Sun Pointe Village in Rutland

700 Rutland Rd N Kelowna BC V1X 7W8 · Residential Care - Licensing

6 inspections

  1. Routine Inspection

    2 infractions

    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The Licensee does not have a system in place to ensure that all fridge/freezer temperatures are monitored as per their policies and procedures. It is noted that not all fridges and/or freezers contain a thermometer, and employees are demonstrating a misunderstanding of thermometer temperatures versus appliance settings. The Licensee states that they will take immediate action regarding temperature monitoring to ensure the safe storing of food items. There is a risk to the health of persons in care if facility policies and procedures are not followed to ensure the safe storage of refrigerated food items. The Licensee will submit a Compliance Plan by July 15, 2026 confirming that the non-compliance with fridge/freezer temperature monitoring has been corrected and include the system that will be implemented for ongoing self-monitoring. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 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 Licensee’s system to ensure all care plans contain all of the legislative requirements is ineffective. In reviewing five care plans it is noted that three do not contain an oral care plan. The Licensee states that they will take immediate action to review care plans to ensure all contain oral care plans. There is a risk to oral health outcomes if a care plan does not contain an oral care plan to guide employees in providing the specific oral care that a person(s) in care requires. The Licensee will submit a Compliance Plan by July 15, 2026 confirming that the non-compliance with oral care plans has been corrected and include the system that will be implemented for ongoing self-monitoring of care plans. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  2. Routine Inspection

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): March 13, 2025 Contravention – The Licensee’s system for ensuring all reportable incidents are submitted to Licensing was noted to be ineffective. During the Licensing Officer’s review of care plans for six persons in care it was noted that one of the persons in care was involved in two reportable incidents that were not submitted to Licensing. Comment – The Licensing Officer discussed with the Manager and Charge Nurse Licensing’s expectations regarding providing details of events leading up to a reportable incident in the reportable incident form submissions.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): March 13, 2025 Contravention – The Licensee did not have a system in place to ensure that all water accessible to persons in care did not exceed 49 degrees Celsius. Water temperature measured in persons in care’s rooms at two differing locations measured 53.8 degrees Celsius. The Manager of Environmental Services took immediate action to decrease the temperature and an immediate Health and Safety Plan was submitted to Licensing outlining employee notification and ongoing monitoring.
    • 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): March 13, 2025 Contravention – The Licensee has a system to ensure that care plans are updated as per the legislation however, the system was noted to be ineffective. Two care plans that were reviewed did not contain updated information for sexual well being in the care plans and/or My Days. The Manager reported that updates and employee education would be conducted immediately. Comment – The Licensee offers a robust recreation plan for persons in care and the Recreation Therapist reported that they are in the process of ensuring that all care plans include the persons in care’s preferences. Comment - During the review of care plans, the Licensing Officer noted that one person in care in a secure neighbourhood and at risk for elopement was fitted with an identification bracelet, and another person in care in a secure neighbourhood and at risk for elopement was not. The Manager reported that a review of policies and procedures for Risk of Elopement will be reviewed and actions taken accordingly.
      • 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)
  3. 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): May 29, 2023 The Licensee has systems in place to ensure that the development of care plans is in compliance however, it was noted during the review of three care plans that the system was ineffective in two areas: 1.) Two care plans were noted to have a directive that was either on the care plan and not on the My Day, or on the My Day and not on the care plan. 2.) Two care plans were noted to not have been updated with a change in status as it pertains to the provision of palliative care, and a sleep charting directive.
      • 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)
      • R10.3K - 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)
  4. 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): February 28, 2020 -It was noted that the Licensee does not have a system in place to ensure that all current employees and future employees are orientated to the Residential Care Regulation. The facility system for the management of concerns brought forward was discussed. The system was noted to be effective. A facility file review conducted from September 2014 to the present date shows that Licensing has received no concerns or complaints for this facility.
      • R2.1T - 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)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): February 28, 2020 -It was noted that the Licensee has a system in place to ensure that the weekly menu is posted in each dining area, however the posted menu contained one snack daily rather than two.
      • 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)
  5. Monitoring

    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): July 20, 2017 -The system for ensuring that staff follow the medication room policies and procedures is ineffective. It was noted during inspection that a staff lunch was in a medication fridge. This was corrected during inspection.
      • 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): July 20, 2017 -The facility's system for ensuring that all staff have obtained a criminal record check prior to commencing employment is ineffective. It was noted that one staff member had commenced employment prior to a criminal record check being obtained. The facility immediately submitted a Health and Safety Plan to Licensing. -The facility's system for ensuring that TB skin tests were completed prior to the staff commencing work is ineffective. The staffing spreadsheet was reviewed and it was noted that it indicated that all staff had not completed TB testing. The staffing spreadsheet indicated that immunization screening was not being completed. The facility reported that they had stopped conducting immunization screening, but effective immediately would add it back into the system.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
  6. Monitoring

    7 infractions

    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): Unable to locate restraint monitoring on person in care file. Unable to locate restraint consent on person in care file.
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): Restraints initiated for multiple persons in care without both person/family consent and physician's order. These events were not reported to Licensing.
    • 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): Emergency policies indicate last total review as 2010-2012.
      • Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Unable to locate admission height on multiple person in care files. Unable to locate physical description on multiple person in care files.
      • Record the height and weight of each person in care on admission; 49 ( 2 )
      • 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)
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Snacks are not routinely provided in all units of the facility. Snack delivery is not delegated to a particular shift routine or job role, and provision of snacks is not monitored by the facility.
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
      • Ensure snacks are provided at times to meet needs of the persons in care (Does not apply to Child and Youth Residential); 64( 1 )(d)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Unlocked hazards in multiple units, within kitchenette areas. Kitchenettes have 1/2 doors that close but do not lock. Unlocked items included cleaning chemicals and staff purses. Unlocked cleaning chemical also noted in person in care bedroom. Carpet staining noted on multiple units. Public bathrooms on units and accessible to persons in care do not have signal/communication devices. Unlocked room off foyer between units houses cleaning carts and provides access to stairs, dumpsters and unsecured outdoor areas. Unit doors are not always locked. Unable to locate weekly menu posted in dining areas. Unlocked medicated creams noted in multiple person in care bedrooms.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Bathrooms must have other equipment that is necessary to protect the health, safety and dignity of persons in care; 30(d)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
      • Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
      • 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): Inconsistencies noted between information sources documenting fall prevention plans. Difficult to ascertain what interventions are to be implemented for an individual person in care.
      • Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)