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The Village at Smith Creek

2425 Orlin Rd West Kelowna BC V4T 3C7 · Residential Care - Licensing

8 inspections

  1. Routine Inspection

    3 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): The system to ensure that the use of a restraint has a current written agreement is ineffective. A review of a Care plan which identified the use of wheelchair seatbelt which the person in care was unable to open, did not have updated agreements from the physician and representative Failure to have current restraint agreements may compromise the health, safety and dignity of persons in care. Submit by April 24, 2026, the plan that will be implemented to come into compliance with Section 74(1)(b) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R2.2A - 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)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): A review of restraint monitoring records indicated that the checks were not consistently charted, and therefore not confirmed as completed. Failure to ensure that restraints are monitored may compromise the health, safety and dignity of persons in care. Submit by April 24, 2026, the plan that will be implemented to come into compliance with Section 84(d) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): During the the review of the physical facility, it was noted that one person in care's bathroom cabinet was not locked. The lock to the cabinet was broken. The system to ensure that that hazardous materials are secured is ineffective. The system to ensure that rooms are kept in a safe conditions is ineffective. Failing to secure person in care's toiletries and ointments may compromise the health and safety of persons in care. Failing to ensure that rooms are in a safe condition may compromise the health, safety and dignity of persons in care. Submit by April 24, 2026, the plan that will be implemented to come into compliance with Sections 22(1)(c) and 35(1)(c) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
  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): October 2, 2024 Contravention – The Licensee does not have a system in place to ensure that orientation to The Community Care and Assisted Living Act and Residential Care Regulation remains a part of new hire orientation. During the inspection the employee orientation checklist was reviewed, and it was noted that the list did not include the required orientation to this legislation. Comment – The Licensee has systems in place to ensure emergency preparedness is in compliance with the legislation. During the inspection September’s fire drill was reviewed along with a new system put into place for emergency evacuations.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): October 2, 2024 Contravention – The Licensee does not have a system in place to ensure that weekly menus remain posted in all dining areas. During the inspection of the physical environment it was noted that some dining rooms continue to not have the weekly menu posted. This is a re-occurring contravention noted during the February 2, 2023 inspection.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
  3. Substantiated complaint

    2 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Allegation – the Licensee is in non-compliance with Residential Care Regulation (RCR) 76(1) - Notification of illness and injury. The allegation was investigated through the review of confidentially submitted documentation and via telephone conversations with the Administrator. As a result, Licensing found that the Licensee did not notify the representative about a person in care’s injury or illness, therefore the allegation that the Licensee is in non-compliance with RCR 76(1) is substantiated.
      • R4.5A - Immediately notify the parent, representative or contact person if a person in care becomes ill or injured while under the care or supervision of the licensee; 76 ( 1 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Allegation – the Licensee is in non-compliance with RCR 50(1) - Continuing accommodation. The allegation was investigated through the review of confidentially submitted documentation and via telephone conversations with the Administrator. As a result, Licensing found that the Licensee did not have documented evidence of an injury or follow-up treatment of the injury, therefore the allegation that the Licensee is in non-compliance with RCR 50(1) is substantiated. Allegation – the Licensee is in non-compliance with RCR 63(5) - Food preparation and service. The allegation was investigated through the review of confidentially submitted documentation and via telephone conversations with the Administrator. As a result, Licensing found that there was not sufficient evidence to confirm whether or not adequate eating time and assistance were provided for one person in care, therefore the allegation of non-compliance with RCR 63(5) is unable to be substantiated.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  4. Routine Inspection

    3 infractions

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The system in place to ensure the posted weekly menu contains two nutritious snacks with at least two food groups is ineffective. During the inspection it was observed that the weekly posted menu only had one snack per day listed.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system in place to ensure the weekly menu is displayed in a prominent place in each dining room is ineffective. During the inspection it was observed that three out of the four units that were toured did not have the weekly menu displayed in a prominent area.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
    • 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 system in place to ensure care plans address behavioural intervention is ineffective. During a review of behavioural care plans it was noted that the care plans did not have sufficient information to safely guide the care of individuals with behavioural concerns.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
  5. Routine Inspection

    3 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): September 29, 2021 The Licensee has a system in place to ensure that orders and consent are received for the use of a restraint, monitoring is in place, and that the use of a restraint is care planned for however; the duration for the use of a restraint was not included in the one restraint care plan that was reviewed.
      • 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)
    • 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): September 29, 2021 The Licensee did not have a system in place to ensure that persons in care and/or their representatives were advised prior to admission on how to express concerns or make complaints to Licensing or the Patient Care Quality Office. The Licensee has posters within the facility containing the contact information for the Patient Care Quality Office. The Licensee has a process in place to ensure that emergency preparedness plans are up-to-date, and that staff are educated to the plans and able to implement them.
      • R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
      • R2.1D - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to the Patient Care Quality Review Board Act; 48( 1 )(c)(ii)
    • 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): September 29, 2021 The Licensee has a system to ensure that care plans are in place and updated however; one behaviour care plan that was reviewed was noted to include one intervention for nights, but no interventions for the mornings or afternoons. The behaviour care plan was not indicated to be in place on the MY DAY. A second care plan that was reviewed was noted to be missing guidance for employees on a condition that required monitoring.
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
      • R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(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): The auditing system in place to ensure that Treatment Administration Record (TAR) documentation is complete is ineffective. On a sampling of persons in care records, it was noted that half of the regular TAR signature spaces were not accounted for by the Care Team (care aides). The site has a system for the LPN to monitor the TARs weekly to ensure that treatments were given and accounted for, although despite checks by the LPNs the TAR documentation did not improve. There is no system in place to ensure that follow up by the LPN is completed or effective.
      • 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): Upon a sampling of person in care records, it was noted that there was no record of information to describe or identify a person in care in the case of an emergency. The admission sheet has a field for these descriptors but in all records reviewed, none of the records had eye colour and hair colour documented. The RN on duty states that this had been addressed a few years ago but seems as though this process has dissolved.
      • 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)
  7. Monitoring

    5 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): July 18, 2017 -The facility's system for ensuring that records of restraint monitoring is ineffective. It was noted during the inspection that restraint documentation was missing the monitoring of the person in care during the use of the restraint.
      • 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)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): July 18, 2017 -The facility's system for ensuring that the next reassessment date for the use of a restraint is in the care plan is ineffective. It was noted during inspection that the next date of reassessment could not be located in the care plan for one person in care who was using a restraint.
      • R10.4O - Provide in the care plan a plan to address, if there is agreement to the use of restraints, the type or nature of restraint and the frequency of reassessment; 81( 3 )(a)(iii)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): July 18, 2017 -The facility does not have a system in place to ensure that the name of the manager is posted, and that the most recent monitoring inspection report is posted. It was noted during the inspection that the manager's name was not posted. It was noted during the inspection that a monitoring inspection report was posted, however it was not the most recent inspection report.
      • R1.1N - Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
      • 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)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): July 18, 2017 -The facility does not have a system in place to ensure that 2 nutritious snacks are posted on the weekly and daily menus. It was noted during the inspection that snacks were not listed on the weekly and daily menus.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): July 18, 2017 -OUTSTANDING from the September 17, 2015 inspection: There is an unlocked gate from the parking lot into an outdoor activity area, and an unlocked door during the daytime that leads from this activity area into the care unit hallway and persons in care's bedrooms. -The facility does not have a system in place to ensure that the weekly menu is posted in each dining area. It was noted during the inspection that the weekly menu was not posted in the dining areas.
      • R7.1AO - Ensure the outside activity area is secured by a fence or other means, if necessary to protect the health and safety of persons in care; 36 ( 2 )
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
  8. Monitoring

    4 infractions

    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Unable to locate admission height/weight on multiple person in care files. Unable to locate physical description on multiple person in care files. Nursing station door unlocked, confidential person in care records stored within
      • 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)
      • 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
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Snack list is consistent with regulations, however, list is not posted where persons in care/families can access it for review- OUTSTANDING
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Toothbrushes and other personal hygiene items stored in multi-person bathrooms not labelled/separated. Clean linen stored on floor in hallway closets. Food fridge temperatures not consistently monitored. No temperature data for past month in one area. -OUTSTANDING
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Broken concrete in pathway creating fall risk Multiple unlocked hazards- flood of water on unlocked shower room floor, unlocked ramp to assisted living portion of building and unsecured kitchen, gate unlocked from pathway to parking lot and door unlocked from same path to care unit hallway by person in care bedrooms. Carpet staining noted throughout facility. Medicated creams noted in two person in care bedrooms.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Ensure all medications are safely and securely stored; 69( 3 )(a)