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Bethesda Kelowna Home

Confidential · Residential Care - Licensing

Official record from Interior Health →

Inspection summary

Bethesda Kelowna Home has been inspected 8 times by Interior Health Authority since July 31, 2015. The most recent inspection, on June 11, 2026, recorded 3 infractions.

2 of 8 inspections on record found no infractions at all. In the past 12 months there was 1 inspection with 3 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 These findings are administrative: the documentation was missing or out of date at the time of inspection.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 8 times across 5 separate inspections, most recently on June 11, 2026. For example: 3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?

  • 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 2 times across 2 separate inspections, most recently on June 11, 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 7 times across 4 separate inspections, most recently on June 11, 2026. For example: 1 - Does the facility provide food services which meet nutritional needs and preferences for 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

    3 infractions

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): It is observed that the current breakfast and lunch menu for a person in care is developed on a one-week rotation. A menu that repeats on a weekly basis, rather than a longer rotation, may increase the risk of nutritional deficiencies if a sufficient variety of foods is not provided. Submit to Licensing by June 26, 2026, a plan outlining how the breakfast and lunch menu will be expanded to a four-week rotation. 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.
      • R5.1B - Develop a menu for persons in care accommodated for greater than 6 weeks, for at least each 4 week period; 62( 1 )(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): It is observed that some cleaning products are not securely stored. When cleaning products are not safely and securely stored, there is a risk that persons in care may ingest or use these products in a manner not intended, which could result in illness or harm. Submit to Licensing by June 03, 2026, a plan outlining how all cleaning agents, chemical products, and other hazardous materials will be safely stored and secured in accordance with legislative 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.
      • 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)
    • R10.3 - 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 one care plan does not include an oral health care plan. When a care plan does not include an oral health care plan, the risk to persons in care is increased, as it does not provide guidance to staff on how to support oral hygiene needs. This may result in inconsistent or missed oral care and can lead to increased risk of tooth decay, gum disease, infection, and associated pain or discomfort. Submit to Licensing by June 26, 2026, a plan outlining how all care plans will include an oral health care plan 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. It is noted that the nutrition care plan in place is insufficient in guiding staff to meet the needs of a person in care. When a nutritional care plan is not sufficient, the risk to persons in care is increased, as it may not adequately identify and address individual nutritional needs. This can result in inadequate intake. In addition, insufficient guidance may lead to inconsistent care and failure to monitor for changes in nutritional status. Submit to Licensing by June 26, 2026, a plan outlining how all care plans will include a nutrition plan 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.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
      • R10.3E - Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)
  2. Routine Inspection

    0 infractions

  3. Routine Inspection

    3 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The Licensee does not have a system in place to ensure that restraint monitoring documentation is retained. During the inspection, it was noted that routine checks are completed throughout the night; however, records related to these checks are not retained.
      • 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): The Licensee's system to ensure that all employees have first aid as required was found to be ineffective. During the inspection, employee files were reviewed and it was noted that first aid for one employee had expired in December 2023. The manager self-identified a second employee that also had expired first aid. A health and safety plan was requested by Licensing at the time of the inspection as employees are, in some circumstances, required to work independently. A plan was submitted to and accepted by Licensing.
      • R3.1O - Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The Licensee does not have a system to ensure that cleaning agents, chemical products and other hazardous materials are securely stored. During the inspection it was noted that cleaning agents are stored in a staff bathroom that is kept open, unlocked and accessible to persons in care. Cleaning agents were also noted to be kept in bedrooms of persons in care.
      • 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)
  4. Routine Inspection

    1 infraction

    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Person in care weights are not consistently being documented at least once each month as required by section 83(4)(a) of the Residential Care Regulation (RCR). Please ensure a system is in place for maintaining compliance.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
  5. Routine Inspection

    0 infractions

  6. Monitoring

    1 infraction

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): November 16, 2017 - UNRESOLVED - The system that is in place to ensure that the facility's policies guide the employees in reportable incidents to Licensing is ineffective. The Licensee has updated the definitions of reportable incidents on the in-house and interagency incident report forms, however the facility's policy for the reporting of reportable incidents to Licensing continues to not list aggression between residents.
      • R2.2F - Ensure there are written policies and procedures regarding responding to reportable incidents; 85( 2 ) (j)
  7. Monitoring

    4 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): October 19, 2016 - The facility's system for ensuring policies are updated and accurate is ineffective. The facility's reportable incident policy is missing aggression between residents in the list of reportable incidents to licensing.
      • Ensure there are written policies and procedures regarding responding to reportable incidents; 85( 2 ) (j)
    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): October 19, 2016 - The facility's system for ensuring compliance with keeping a clear and up to date record of immunization status for persons in care is ineffective. The immunization record listed 2015 influenza immunization date, and not any previous years.
      • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): October 19, 2016 - The facility's process for monitoring compliance with keeping a record of admission date, height, and weight is ineffective. LO was unable to locate admission weight, height and date in the person in care's charts.
      • Record the height and weight of each person in care on admission; 49 ( 2 )
      • Keep for each person a record showing the date of admission to the facility; 78( 1 )(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): October 19, 2016 - UNRESOLVED - The facility's system for ensuring compliance with the safe storage of food is ineffective. The facility is currently recording the fridge temperatures once a month. LO inquired how they are able to ensure that the food is stored at a safe temperature when it is only monitored and recorded once a month. The assistant manager stated that he could not ensure the safe storage of food at a safe temperature and he will immediately start to monitor it daily.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  8. Monitoring

    5 infractions

    • 2.2 Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): Unable to locate a fall policy or routine fall risk screening. One person in care is deemed at risk for falls and does have an appropriate fall prevention plan.
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): Unable to locate any restraint monitoring documentation.
      • 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)
    • 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 resolution process does not clearly indicate the role of Licensing and PCQO, and how these services can be accessed. Emergency preparedness binder is complex and may be difficult to navigate in times of emergency. Key emergency policies should be indicated by flagging, tabs or other means of quick identification.
      • Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
      • 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)
      • Make all policies and procedures available to employees at all times, to licensing, a person in care and the parent/representative on request; 85( 1 )( c) (i)(ii)(ii.1)(iii)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Food fridge temperatures not monitored for past two months.
    • 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): Unable to locate any pre-admission screening for risk of falls, elopement or aggression.
      • Screen the person before admission to ensure they will receive both safe and adequate care; 47 ( 1 )
      • Ensure the screening process considers the training and experience of employees, the number of employees and patterns of employee coverage; 47( 2 )(a)
      • Ensure the screening processes considers the health, safety and dignity of other persons in care; 47( 2 )(d)
      • Assess each person in care on admission to determine the risk that they may leave the facility without notification of an employee; 49 ( 3 )
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