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Bethesda East Kelowna Home

Confidential · Residential Care - Licensing

Official record from Interior Health →

Inspection summary

Bethesda East Kelowna Home has been inspected 8 times by Interior Health Authority since September 11, 2015. The most recent inspection, on August 18, 2026, recorded 5 infractions.

1 of 8 inspections on record found no infractions at all. In the past 12 months there was 1 inspection with 5 infractions recorded. All recorded findings relate to upkeep, equipment or paperwork rather than direct health risks.

The number of infractions per inspection has stayed roughly the same over time.

What these findings mean

Health authorities word their findings differently, so we group them by what they mean for the people in care. Higher-risk findings are the ones that could directly make someone sick, and they matter more here because young children, older adults and people who are unwell are more vulnerable to infection.

  • Permits, records and postingLower risk

    Operating permits, required signage, written procedures and logs. These findings are administrative: the documentation was missing or out of date at the time of inspection.

    Recorded 14 times across 7 separate inspections, most recently on August 18, 2026. For example: 1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?

  • Equipment and utensilsLower risk

    Equipment has to be made of cleanable materials, kept in good repair and stored properly. These findings are mostly about upkeep, like a cracked surface or worn part. They are generally lower risk but show how well the place is maintained.

    Recorded 5 times across 5 separate inspections, most recently on August 18, 2026. For example: 1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?

  • Other findingsLower risk

    Findings that do not fit the categories above, such as follow-ups that confirm an earlier violation was corrected, or requirements specific to this type of facility.

    Recorded 6 times across 5 separate inspections, most recently on August 18, 2026. For example: 2 - Do care and supervision practices ensure health, safety and dignity of persons in care?

About this data

These results come from Interior Health Authority, which inspects food premises and other public facilities in this area. We republish the authority's public disclosure data and refresh it regularly; the official record is the final word.

8 inspections

  1. Routine Inspection

    5 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): Through discussion with the interim manager, it was identified that there is no process in place to ensure incoming management are informed of active compliance plans and associated requirements. As a result, the interim manager was unaware of compliance plans currently in place at the facility. When management is not aware of existing compliance plans, required measures may not be implemented, monitored, or communicated to staff. This may result in ongoing non-compliance and increased risk to the health, safety, and well-being of persons in care. Submit to Licensing by September 4, 2026, a plan outlining the measures that will be implemented to ensure all new management and employees are informed of existing compliance plans and their associated requirements. 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.
      • 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)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): A review of person in care records indicates that monthly weights are not being consistently documented. When weights are not consistently recorded, it may be difficult to identify or monitor nutritional concerns or changes in health status associated with unintended weight loss or weight gain. This may result in delays in recognizing and addressing potential health concerns. Submit to Licensing by September 4, 2026, a plan outlining the measures that will be implemented to ensure weights are obtained and documented monthly for all persons in care, as required by the legislation. 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.
      • R4.1U - 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): It is observed that vents throughout the home are covered in dust. Additionally, extensive cobwebs are noted on multiple exterior light fixtures in the outdoor space used by persons in care. The manager advises that there is system in place to ensure the yard is maintained; however, there is currently no system to ensure the space is maintained in a clean condition. When common areas are not maintained in a clean condition, the accumulation of dust, debris, and other environmental contaminants may impact the health, safety, and comfort of persons in care and may impede their safe use and enjoyment of the space. Submit to Licensing by September 4, 2026, a plan outlining the measures that will be implemented to ensure all common areas, both indoor and outdoor, are maintained in a safe and clean condition. 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.
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It is noted that one person in care is at risk of elopement and would not be able to identify themselves. This person does not wear a bracelet or other means of identification. If a person elopes and has no way of identifying themselves, delays in locating them or confirming their identity could occur, potentially resulting in harm or injury. Submit to Licensing by September 04, 2026, a plan outlining the measures that will be implemented to ensure the person can be readily identified in the event of an elopement. 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.
      • 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)
    • 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): A review of person in care care plans indicates that some information has not been updated to reflect the current needs and circumstances of persons in care. Additionally, one care plan does not include information necessary to implement a previously submitted compliance plan related to the management of the person's financial decisions. When care plans are not updated to reflect current information, staff may not have accurate information to guide the provision of care and services. This may result in care that does not meet the current needs of persons in care and may increase the risk of unmet care needs. Submit to Licensing by September 4, 2026, a plan outlining the measures that will be implemented to ensure care plans are reviewed and updated to reflect current information, as required by the legislation. 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.
      • 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): During the inspection, medication administration records (MARs) were reviewed and in one MAR it was noted that four out of seven as needed (PRN) medications did not have the effectiveness documented. Not documenting PRN effectiveness may increase the risk to the persons in care as thy may not receive their as needed medications in a manner that meets their needs. Submit by May 30, 2025, a plan outlining how it will be ensured that the effectiveness of PRN medications will be documented. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): During the inspection, it was noted that an unlabeled tube of toothpaste and brush were left in a bathroom which is used by more than one person in care. Unlabeled personal hygiene items stored in public areas may increase the risk of disease transmission among persons in care. Submit by May 30, 2025, a plan outlining how personal hygiene items will be stored and labeled in a manner that mitigates risk of disease transmission between persons in care. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • 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): During the inspection, the door to the medication room was observed to be open and unlocked. The door was closed and locked during the inspection. Unsecured storage of prescription medications may increase risk to persons in care, with potential of medications to be taken incorrectly and lead to adverse reactions. Submit by May 30, 2025, a plan outlining how it will be ensured that medications will be safely and securely stored. The plan must include the system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
  3. 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): The Licensee's system to ensure checklists are completed as required was found to be ineffective. During the inspection, the night checklist was noted to be missing 17 initials over the span of 2 months. Another document, a medication double check, was noted to be missing 12 out of 30 checks.
      • 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): The Licensee's system to ensure water that is accessible to a person in care does not exceed 49 degrees Celsius was found to be ineffective. During the inspection, water temperature in the kitchen was checked and was noted to exceed 49 degrees Celsius.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
  4. Routine Inspection

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The Residents' Bill of Rights was not displayed in a prominent place in the facility at the time of inspection.
      • R1.1Y - Display the rights of adult persons in care in a prominent place and in a form acceptable to the minister; Act 7( 1 )(c.1)(i)(ii)
    • RB1.19 - Are rights of adult persons in care displayed in a form and in the manner acceptable to the minister?
      • Observation(s): Residents' Bill of Rights not posted at time of inspection.
      • RB1.19A - Display the rights of adult persons in care in a form and manner acceptable to the minister.
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Door to medication storage room could not be adequately closed and locked at time of inspection. Please ensure a temporary system for the safe storage of medications is implemented while waiting to have door fixed.
      • 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)
  5. Routine Inspection

    0 infractions

  6. Monitoring

    2 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The monitoring system in place to ensure compliance with the documentation of PRN effectiveness in the persons in care's medication record (MAR) is ineffective. PRN effectiveness is documented more frequently that it was last year, however the documentation remains inconsistent.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 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 facility's reportable incident policy does not include aggression between residents as required by schedule D of the Residential Care Regulation. The facility does not have a procedure and policy in place to guide employees in the event of a disease outbreak or for outbreak prevention. The facility does not have a policy and procedure in place for the orientation of new employees.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • 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)
  7. Monitoring

    6 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): January 23, 2017 - The facility's system for ensuring compliance with recording the effectiveness for PRNs administered is ineffective. LO reviewed the medication records for persons in care and found the effectiveness for PRNs administered to be inconsistently documented.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): January 23, 2017 - The facility's system to ensure compliance with documenting the outcome of restraint reassessments is ineffective. The facility is reassessing the restraints yearly, however the outcome of the reassessment is not being documented.
      • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): January 23, 2017 - The facility's system for ensuring compliance with reporting reportable incidents involving persons in care to Licensing is ineffective. LO and manager discussed schedule D of the Residential Care Regulations. LO explained the definition for each reportable category, and the manager stated there is at least two incidents that have occurred that meet the criteria for reportable incidents. The manager stated she will review all in house incident reports for the last year, and will submit incident reports to Licensing or any reportable incidents identified..
      • 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)
    • 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): January 23, 2017 - The facility's system for ensuring compliance with employees implementing the facility's reportable incident policy and procedure is ineffective. The facility has not been submitting incident reports to Licensing for persons in care who are involved in reportable incidents.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): January 23, 2017 - The facility's system for ensuring compliance with recording the height and weight of each person in care on admission is ineffective. LO inspected persons in care's charts and was unable to locate their admission height and weight.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
    • R4.6 - Are facility records current and complete?
      • Observation(s): January 23, 2017 - The facility's system for retaining records of compliance with family and resident council meeting minutes is ineffective. The facility has annual family/resident council meetings however, there is no record of who attended, topics discussed, or any items requiring action.
      • R4.6H - Retain records of compliance with family and resident council required in section 59; 89( 2 )(b)
  8. Monitoring

    4 infractions

    • 4.3 Is documentation concerning restraints adequate?
      • Observation(s): Unable to locate restraint monitoring for multiple persons in care.
      • 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)
    • 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): Complaint brochure does not include contact information for licensing.
      • Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Expired first aid certificates noted on multiple staff files.
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Door to room containing medication fridge found open. Plastic bottles noted in multiple areas of facility while person in care at documented risk for biting/eating bottles self-propelling in wheelchair. Injectable medication found in food fridge.
      • 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)
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