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The Vineyards Residence

726 Valley Rd Kelowna BC V1V 0E9 · Residential Care - Licensing

8 inspections

  1. Routine Inspection

    0 infractions

  2. Routine Inspection

    3 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The Licensee's system to ensure that restraint monitoring is completed at the time the restraint is in place, was found to be ineffective. During the inspection, three separate restraint monitoring documents were reviewed, and it was noted that one had not been completed as required.
      • 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): The Licensee's system to ensure chemical products and other hazardous materials are securely stored was found to be ineffective. During the inspection, chemicals were observed to be in an unlocked cupboard which is accessible to persons in care. In the same area it was also observed that persons in care have access to hot water and an unlocked cupboard which contained broken glass.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee's system to ensure persons in care who leave the facility temporarily are in possession of written documentation with their name, facility name and emergency contact information was found to be ineffective. During the inspection it was noted that there is a sign out and sign in process for persons in care who are leaving the facility. It was also noted that there are armbands available that meet the requirement for having identification while away from the facility; however, there is no system in place to ensure persons in care are given these armbands prior to leaving the facility. During the inspection it was noted that the Licensee does not have a system in place to ensure persons in care who may leave the facility without notifying an employee be fitted with a bracelet or other means that can not be easily removed.
      • 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 )
      • 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. Substantiated complaint

    1 infraction

    • 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): Allegation: The Licensee is in non-compliance with Residential Care Regulation (RCR) section 85(1)(d) as it relates to required documentation not being sent with paramedics to the hospital. Findings: Substantiated. During the investigation, care notes were reviewed, and the documentation indicates that documents were sent with the paramedics. The facility’s policy for transfer to the hospital was reviewed and it was noted that progress notes leading up to the emergency must be sent with the resident. During the investigation it was determined that progress notes were not sent, as required by the facility's policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  4. Substantiated complaint

    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): Contravention - During the investigation, the Licensed Practical Nurse (LPN) and Health Care Aide (HCA) orientation checklists were reviewed, and it was noted that the Licensee does not have a system in place to ensure that all employees are orientated to the Community Care and Assisted Living Act (CCALA) and Residential Care Regulation (RCR).
      • 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Allegation - The Licensee is in non-compliance with RCR 37(1)(d)(e) as it pertains to obtaining all the required documentation for employee records. Findings - UNSUBSTANTIATED. During the investigation, it was determined that the Licensee has a system in place to ensure that required documentation for employment is obtained. Four employee files of differing hiring dates and designations were randomly selected and reviewed. All files contained a completed checklist and the appropriate documentation. Allegation - The Licensee is in non-compliance with RCR 41(2)(c) as it pertains to designating an employee to manage unusual situations or emergencies. Findings - UNSUBSTANTIATED. During the investigation, it was determined that the Licensee has a system in place to notify management in case of an unusual situation or emergency. The emergency planning binder, the decision tree and the phone list of management/who to contact in an emergency were all reviewed. These resources were noted to be available at each nursing station. Allegation -The Licensee is in non-compliance with RCR 51(3) as it pertains to ensuring all employees are trained in the implementation of the emergency plans. Finding - UNSUBSTANTIATED. During the investigation, it was determined that the Licensee has a system in place to ensure employees are trained in the implementation of emergency plans. This was evidenced by the review of completed fire drills and attendance records. Fire and emergency procedures are also included in the LPN and HCA orientation checklist with the location of emergency binders, pull stations, fire extinguishers and alert panels. Allegation - The Licensee is in non-compliance with RCR 68(4) as it pertains to employees complying with the policies and procedures of the medication safety and advisory committee (MSAC) for narcotic medication administration. Findings - SUBSTANTIATED. During the investigation, the MSAC policy and the medication administration policy was reviewed. The administration policy states that a narcotic count must be done at the beginning and end of each shift; however, during the inspection narcotic count documents were reviewed and revealed that narcotic count is only completed at the end of the day shift and the beginning of evening shift.
      • R3.1E - Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37( 1 )(d)
      • R3.1Q - Designate an employee qualified by training and experience to supervise employees who provide care to persons in care, coordinate and monitor the care of persons in care and manage unusual situations or emergencies; 41( 2 )(a)(b)( c)
      • R3.1Z - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
      • R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
  5. Routine Inspection

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The Licensee's system to ensure all incidents are reported to Licensing was found to be ineffective. During the inspection, internal incident reports were reviewed and one, which was not reported to Licensing, was found to be reportable. In addition, LO Hensel requested that internal incident reports be reviewed and any incidents that were found to be reportable, be submitted to Licensing.
      • 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)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): During the inspection it was noted that the posted menu did not include snacks.
      • 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 Licensee's system to ensure that the weekly menu is displayed in a prominent place in each dining room was found to be inefficient. During the inspection, two separate dining rooms were inspected and one of them did not have the menu displayed in a prominent place.
      • R7.1AQ - Display the weekly menu in a prominent place in each dining area; (Applies only to Long Term Care) 62 ( 4 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The Licensee's system to ensure that all medications are labelled correctly was found to be ineffective. During the inspection three bottles of medications were noted to have hand written initials on them with no medication label from the pharmacy. This was also noted at the most recent medication safety advisory committee meeting in April 2023.
      • R9.1E - Administer only medications prescribed or ordered by the medical or nurse practitioner; 70 ( 1 )
  6. Routine Inspection Follow-up

    0 infractions

  7. Routine Inspection Follow-up

    0 infractions

  8. Routine Inspection

    1 infraction

    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): -Licensing was advised persons in care do not carry documentation stating name, facility name and emergency contact information when leaving the facility. Persons in care assessed as a wandering risk wear bracelets with their name. -Persons in care with meals provided by ongoing room tray service are not indicated in the care plan or approved by a medical practitioner. A managed risk assessment has been used instead.
      • 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 )
      • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)