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Three Links Manor

1449 Kelglen Crescent Kelowna BC V1Y 8P4 · Residential Care - Licensing

10 inspections

  1. Routine Inspection

    2 infractions

    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): It is noted that two bottles of medication in the medication cart do not have pharmacy labels. A person in care's name is observed to be written on the bottles with a marker. Having medication bottles without correct pharmacy labels may increase the risk of medication being administered incorrectly. Submit to Licensing by May 05, 2026, a plan outlining how all medication will be packaged appropriately. 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.
      • R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(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): It is noted that some care plans for wounds are missing details, specifically the frequency of wound care required. This lack of direction may pose a risk for inconsistent wound management and may impact wound healing outcomes. Submit to Licensing by May 05, 2026, a plan outlining how wound care plans will be developed to ensure they appropriately guide staff in the management of wounds. 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.
      • R10.3M - 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
  2. Routine Inspection

    3 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The Licensee's system to ensure the follow up of as needed (PRN) medications is documented was found to be ineffective. During the inspection, person in care's medication administration records (MAR's) were reviewed and in one instance 18 out of 42 times the effectiveness of a PRN was not documented. In another instance 13 out of 48 times the effectiveness of a PRN was not documented.
      • 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): The Licensee's system to ensure all person in care records and personal information is kept confidential was found to be ineffective. During the inspection, it was noted that some person in care records were stored in a filing cabinet which was unlocked in a room that was accessible to families and persons in care.
      • R4.1V - 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
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): During the inspection it was noted that a door with a keypad lock on it was not in working order. It was determined by staff that this door was suppose to be locked and chemicals were noted to be located in the room. When this was brought to the attention of management, the issue was immediately rectified and the door lock was repaired.
      • 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)
  3. Routine Inspection

    1 infraction

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Licensee's process to ensure that all snacks include 2 food groups was found to be ineffective. During the inspection it was noted that the menu included 2 daily snacks but that these snacks did not include 2 food groups as described in Canada's Food Guide.
      • 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)
  4. Routine Inspection

    3 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): It was noted during the inspection that the system to ensure restraint monitoring is documented was ineffective. Restraint monitoring documentation was evident, however, was noted to have not been completed on some charts since 2021.
      • 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Upon review of treatment administration records, it was noted that the system to ensure they are completed was ineffective. Treatment administration records on the first floor were incomplete, however, the treatment administration records on the second floor were noted to be completed consistently.
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 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 to ensure each care plan is reviewed or modified at least once a year was ineffective. During the inspection it was identified that smoking care plans did not show evidence of review or revision. It was also noted that multiple AGG care plans did not have evidence of a review or update. It was also noted during the inspection that the falls care plan located in the person in cares room was out dated.
      • 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)
  5. 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 system in place for monitoring the physical environment to ensure the most recent inspection report is displayed is ineffective. This was resolved during the inspection as the manager printed and posted the most recent inspection report in a prominent area.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system in place to ensure to ensure persons in care's admission weight are recorded on admission is ineffective. Licensing Officer reviewed a recently admitted person in care's chart and noted their admission weight had not been recorded. During the inspection the Care Coordinator requested the person to be weighed and it was entered into their chart.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
  6. Monitoring

    1 infraction

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The system that is in place to ensure compliance with keeping a record of the reassessments of restraints is ineffective. LO reviewed 3 charts with restraint care plans in place and one person in care had 2 restraints in place since 2017 and there is no documented evidence of the reassessments of the restraints.
      • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
  7. Monitoring

    3 infractions

    • R4.6 - Are facility records current and complete?
      • Observation(s): March 15, 2017 - The facility does not have a system in place to ensure compliance with monitoring of the food services and nutrition care the facility provides to persons in care. The food service supervisor and the food service manager confirmed there is currently no system in place for the monitoring and auditing of the food services and nutrition care that is provided to persons in care.
      • R4.6D - Retain the results of monitoring of food services and nutrition care; 87(c)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): March 15, 2017 - The facility does not have a system in place to monitor the physical environment of the tub rooms. LO inspected four tub rooms and found unlabelled personal hygiene items in 3/4 of the rooms. All unlabelled personal hygiene items were discarded during the inspection.
      • R6.3A - Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): March 15, 2017 - The facility does not have a system in place to ensure all common areas of the building are in a good state of repair. LO observed pillars in common areas and hallway entrances to have damaged areas requiring repair and paint. The manager stated that the maintenance plan was to complete all of the repairs over the winter, however they have not been completed.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  8. Monitoring

    10 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): September 27, 2016 - UNRESOLVED - The facility's process for ensuring employee compliance with the documentation for medications and treatments administered is ineffective. LO reviewed MARs and TARs that were missing initials for the routine medications administered, and the PRN effectiveness.
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): September 27, 2016 -UNRESOLVED - The facility does not have a system in place to ensure compliance with monitoring of persons in care while in restraints. LO reviewed the restraint monitoring sheets. One persons in care's restraint monitoring sheet did not contain restraint monitoring documentation since Sept 24, 2016. The person in care was at the facility and safe. Four persons in care's monitoring sheets had not been documented on since the previous day.
      • 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)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): September 27, 2016 - -UNRESOLVED- The facility's process for ensuring employees follow all persons in care's restraint care plans and monitor them throughout the use of the restraint is ineffective. LO reviewed the restraint monitoring sheets. One person in care's restraint monitoring sheet did not contain restraint monitoring documentation since Sept 24, 2016. The person in care was at the facility and safe. Four other persons in care's restraint monitoring documentation had not been recorded on since the previous day.
      • Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): September 27, 2016 - The current system that the facility has in place to ensure compliance with the monitoring of the physical environment and services provided is ineffective. LO observed one wall and a section of the ceiling in the upstairs dining room solarium that had red food splattered on it. LO discovered Cavi wipes in a person in care's bathroom leaving hazardous materials accessible to persons in care. LO observed wound care sheets that were incomplete. The facility does not currently have a system in place to monitor the completion of wound care and the documentation of the wound care provided. LO observed MARs and TARs that were missing initials for routine medications and treatments administered. The PRN effectiveness was not consistently documented for PRN medications and PRN treatments administered.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 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 27, 2016 - The facility's process for ensuring compliance with employees following facility policies is ineffective. The facility is currently not orientating new employees to the Residential Care Regulations and the Community Care Assisted Living Act. UNRESOLVED - The employees are not following the facility's restraint policy. LO reviewed the restraint monitoring sheets. One person in care's restraint monitoring sheet did not contain restraint monitoring documentation since Sept 24, 2016. The person in care was at the facility and safe. Four persons in care's monitoring sheets had not been documented on since the previous day.
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): September 27, 2016 - The facility put a process in place to ensure compliance with recording admission Height and Weight. The process did not include ensuring compliance with recording of persons in care's admission date. LO reviewed a sampling of seven persons in care's charts and found three charts that did not contain documented admission dates. UNRESOLVED - The facility does not have a process in place to ensure compliance with each persons in care' s chart containing a signed consent to contact a physician or ambulance. LO reviewed a sampling of seven persons in care's charts and found two charts that did not contain a signed consent form.
      • Keep for each person a record showing the date of admission to the facility; 78( 1 )(b)
      • Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): September 27, 2016 - The facility does not currently have a process in place to ensure the safe storage of food in persons in care's personal fridges located in their rooms. UNRESOLVED - The facility's process for monitoring the compliance with assisting persons in care in maintaining health and hygiene is ineffective. During the physical environment inspection LO observed unlabelled hair combs, brushes, nail clippers and nail files stored in a cupboard in the first floor tub room.
      • 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): September 27, 2016 - The facility's process for inspecting and monitoring of the physical environment to ensure compliance with the Residential Care Regulations is ineffective. LO observed one wall and a section of the ceiling in the upstairs dining room solarium that had red food splattered on it. During the physical building inspection LO observed a maintenance shed with gas, and other hazardous items stored in it. The doors were open and unlocked. The doors to the court yard are left unlocked to allow persons in care to roam outside as they wish in the nice weather. There were two persons in care outside at the time that the shed was unlocked and unattended. UNRESOLVED - LO discovered Cavi wipes in a resident's bathroom leaving hazardous materials accessible to persons in care.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 9.1 Are medications stored, handled, and administered appropriately?
      • Observation(s): September 27, 2016 - UNRESOLVED - The facility's process for ensuring employee compliance with the documentation for medications and treatments administered is ineffective. LO reviewed MARs and TARs that were missing initials for the routine medications administered, and the PRN effectiveness. (2) A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care 78 2(b)
    • 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): September 27, 2016 - The facility's process for ensuring persons in care's care plans are revised and updated yearly or when a person in care has a change in their condition is ineffective. LO reviewed a sampling of seven persons in care's charts and observed in three charts that the care plans had not been updated within the last year or upon change in persons in care's condition.
      • 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)
  9. Monitoring

    10 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): PRN documentation of the reason and result for the medication in PIC TAR's and MAR's was observed to be inconsistently charted during this inspection. This infraction was noted during the facilities last two routine inspections and found unresolved during this inspection.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): Incident reports received by licensing have been incomplete of required information on multiple occasions since the last routine inspection. Licensing has been in contact with facility to discuss incident reporting procedures during this time. Facility RCC indicated incident reporting procedures are being worked on with staff currently. The licensee has been asked to provide licensing with a plan on how reportable incidents will be received by licensing in the form and manner required. LO has requested the licensee to submit a new monitoring plan and process to ensure compliance.
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): It was noted that an audited PIC chart was missing the TB screening. RCC stated was thinned from chart and new TB screen obtained.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): -The restraint care plans located in resident's charts were found to be incomplete. On the day of the inspection restraint monitoring had not been documented every 2 hours as required by IHA policy.
      • Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
      • Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
      • 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)
    • 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): It was noted that PRN medications that were being administered to several PIC did not indicate the effectiveness. Employees found to not be following the IHA restraint policy. There was no documentation for the monitoring of residents while in restraints on the day of inspection.
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): PRN documentation of the reason and result for the medication in PIC TAR's and MAR's was observed to be inconsistently charted during this inspection. This infraction was noted during the facilities last two routine inspection and found unresolved during this inspection. Staffing records which confirm, first aid, CPR, CRC, ref check, TC screening, immunization, and food safe are not available. IHA policy reflects the requirements of the residential care regulations for employee files. Individual employee files are not kept on site and therefore unable for licensing to review.
      • Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
      • Obtain character references for all employed persons; 37( 1 )(b)
      • Obtain a record of work history for all employed persons; 37( 1 )(c)
      • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37( 1 )(d)
      • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
      • Ensure that employed persons are of good character; 37( 2 )(a), Act 7( 1 )(a)
      • A person must not be employed unless the licensee is satisfied based on information available that the person has the personality, ability and temperament necessary to manage or work with persons in care 37( 2 )(b)
      • Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Admission height and weight not included on charts audited. It was noted that a PIC chart was missing the consent to call MD/ambulance. (CDI)
      • Record the height and weight of each person in care on admission; 49 ( 2 )
      • Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
    • 4.6 Are facility records current and complete?
      • Observation(s): -It was noted that there is no written documentation or evidence of food audits being conducted. -It was noted that there is no written documentation of the complaint record.
      • Retain the results of monitoring of food services and nutrition care; 87(c)
      • Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): -It was noted that medication cabinets in PIC washrooms which store prescribed medicated items were observed on several occasions unlocked during this inspection. This infraction was noted on the last two licensing inspection and found unresolved during this visit. -It was noted that on several occasions cavi-wipes were left in PIC's bathroom. -It was noted that the cover was off of the hot water tap in dining area during inspection. -It was noted that there were razors, cavi-wipes accessible, scissors (foot care tin with multiple tools ) in tub room which the door was left open an accessible to PIC. (CDI) -It was noted that during inspection the cleaning cart had disinfectant, bleach, and cavi-wipes that were unlocked and accessible to PIC. (CDI) -It was noted in the recreation area that there was bleach in an unlocked cupboard accessible to PIC in service room. (CDI) -It was noted that a post in the upstairs PIC dining room has significant damage(paint totally peeled off),
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
      • Provide a safe and secure storage area for self-administered medications; 69( 3 )(b)(i)
    • 10.1 Does the admission screening ensure the health, safety and dignity of persons in care and the rights of adult persons in care?
      • Observation(s): TB screening missing in a PIC chart. RCC stated was thinned from chart and new TB screen obtained..
      • Ensure the screening processes considers the health, safety and dignity of other persons in care; 47( 2 )(d)
  10. Monitoring

    6 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): PRN documentation of the reason and result for the medication in PIC TAR's and MAR's was observed to be inconsistently charted during this inspection. This infraction was noted during the facilities last routine inspection and found unresolved during this inspection. Some MAR's observed had missed charting of medications, codes provided in MAR to explain the reason for missed charting were not utilized.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): Incident reports received by licensing have been incomplete of required information on multiple occasions since the last routine inspection. Licensing has been in contact with facility to discuss incident reporting procedures during this time. Facility RCC indicated incident reporting procedures are being worked on with staff currently. Please provide licensing with a plan on how reportable incidents will be received by licensing in the form and manner required.
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • 23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
      • Observation(s): In discussion with staff and RCC there are some PIC's who are able to leave the building independently, PIC's do carry identification. Ensure the care plans for these individuals include specific instructions for staff to follow regarding PIC's time away form facility (how long can PIC be away, what steps to take if they do not return to facility on time, weather restrictions etc..). Ensure representatives for PIC's who are able to leave independently are are aware of plan and that the plan is reviewed during care conferences or as required.
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Height and weight not included on some admission PIC forms reviewed. Identification information (hair/eye colour) missing on several PIC charts.
      • Record the height and weight of each person in care on admission; 49 ( 6 )
      • 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)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Facility has recently installed a video surveillance system which covers most common areas of the premises, ensure a notice is posted in a prominent place to inform all visitors of the video monitoring system. Staff belonging's (purses, backpacks) observed in an area accessible to PIC's. Ensure staff personal items are stored in an area which is inaccessible to PIC's to avoid potential access to hazardous items (lighters, medication, sharps, food items that may cause allergic or food texture problems). This infraction was noted on the last licensing inspection and found unresolved during this visit. Medication cabinets in PIC washrooms which store prescribed medicated items were observed on several occasions unlocked during this inspection. This infraction was noted on the last licensing inspection and found unresolved during this visit.
      • Display a notice in a prominent place if electronic surveillance is being used to transmit or record images of persons in care or members of the public; 19 ( 23 )
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
      • Provide a safe and secure storage area for self-administered medications; 69( 3 )(b)(i)
    • 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): In discussion with staff and RCC there are some PIC's who are able to leave the building independently, PIC's do carry identification. Ensure the care plans for these individuals include specific instructions for staff to follow regarding PIC's time away form facility (how long can PIC be away, what steps to take if they do not return to facility on time, weather restrictions etc..). Ensure representatives for PIC's who are able to leave independently are are aware of plan and that the plan is reviewed during care conferences or as required.
      • 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)