Mariposa Gardens Community & Retirement Living
8816 97 St Osoyoos BC V0H 1V5 · Residential Care - Licensing
12 inspections
- Routine Inspection
2 infractions
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): September 17, 2025 The Licensee does not have a system to ensure that in each person in care’s room there is a safe, secure place in which the person in care may store valuable property. During a tour of three persons in care’s rooms there was only one that contained a safe, secure place as per the legislation. Failure to ensure there is a safe, secure place to store valuables for persons in care who wish to utilize safe storage may pose a risk to the promotion of their independence and dignity. The Licensee will submit a Compliance Plan to Licensing by October 8, 2025 confirming that the non-compliance with the provision of a safe, secure place in persons in care’s rooms has been corrected. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
- R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 1 ) (a)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): September 17, 2025 The Licensee does not have a system in place to ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identifying themselves be fitted with a bracelet or other means that cannot be removed easily, and contains the person in care’s name, facility name, and emergency contact information. Failure to ensure that this identification system is in place for those who it pertains to may result in an increased risk of harm to the person in care should they elope from the facility. The Licensee will submit a Compliance Plan to Licensing by October 8, 2025 confirming that the non-compliance with the provision of identification to persons in care who it pertains to has been corrected. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Substantiated complaint
2 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Contravention arising from the investigation – It is apparent by the contraventions noted in this report that the Licensee does not have systems in place to self-monitor the noted sections of the RCR to ensure compliance. Failure to self-monitor for compliance with the legislation may increase risk to persons in care's health and safety, as their care needs may not be met. The Licensee will submit a Compliance Plan by September 26, 2025 confirming that non-compliance with self-monitoring has been corrected and include the system that will be implemented for ongoing self-monitoring of the physical environment, and the care and services provided to persons in care. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- 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): Allegation – the Licensee is in non-compliance with RCR 81(2)(b) as it pertains to the Licensee moving a person in care’s bed away from the wall, a fall sustained by the person in care out of that side of the bed after it was moved, and the representative being unable to receive their requested information regarding details of the fall, and falls prevention strategies that were or were not being implemented at the time of the fall. The Licensee provided documentation for the investigation including, but not limited to, Nursing progress notes, Physiotherapy assessments, Medication administration records, Care plan, and Care conference documentation. The Licensing Officer conducted a thorough review of the documentation and noted the following: -Documentation was not in place regarding the last time the person in care was checked and their status prior to being found at 06:10 after having sustained a fall on May 27th. -Documentation states that the representative was told by a team member that if the bed was moved away from the wall and the person in care was a high falls risk, the bed could be lowered and falls mats used. -Documentation states that three days after the representative was provided with this statement the person in care, “was found sitting next to (their) bed with a large hematoma to (their) left forehead and specks of blood (on the forehead).” There is no further documentation of the details of the fall or whether the discussed falls prevention strategies were in place at the time of the fall. -Documentation states that after the fall occurred the bed was lowered, and the call bell was placed within reach. In conclusion, documentation was not in place for details leading up to the fall including when the person in care was last checked and their status at that time, documentation does not contain details of the position of the person in care after the fall and whether the falls prevention strategies discussed with the representative three days prior to the fall were in place, therefore, based on a balance of probability, the Licensing Officer finds the allegation of non-compliance with RCR 81(2)(b) SUBSTANTIATED. There is risk to persons in care when their care plan is not developed in a manner that takes into account their unique abilities, physical, social and emotional needs. In this case care planning for falls prevention strategies were not clear and/or being implemented and the person in care sustained a fall from their bed resulting in an injury. The Licensee will submit a Compliance Plan by September 26, 2025 confirming that the non-compliance with care planning has been corrected and include the system that will be implemented for ongoing self-monitoring of the physical environment, and the care and services provided to persons in care. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance. Contravention arising from the investigation – During a review of documentation submitted by the Licensee, it was noted that the person in care’s treatment plan put into place for a head wound resulting from a fall was not documented as being completed on 8 occasions during the 11-day treatment plan. Failure to conduct wound care treatment as required could result in worsening of the condition, thus increasing the risk to persons in care's health outcomes. In addition, during a review of Nursing progress notes, the documentation stated that the falls mat(s) had not been placed at the bed for 2 consecutive nights after the fall. The falls mat(s) were ordered to mitigate risk of injury should the person sustain a fall from the bed, and not utilizing the mat(s) increases the risk of injury to the person in care. The Licensee will submit a Compliance Plan by September 26, 2025 confirming that non-compliance with the documenting and/or conducting of wound care, and implementation of falls mats has been corrected and include the system that will be implemented for ongoing self-monitoring of the physical environment, and the care and services provided to persons in care. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
- R10.3A - 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) (Show More)
- 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
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection Follow-up
5 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Contravention – A complaint from a member of the public was brought forward to the Licensee who conducted an investigation in response. A reportable incident for alleged neglect was then submitted to Licensing and an investigation was subsequently conducted. Non-compliance was identified by both the Licensee and Licensing. It is apparent by the contraventions noted in this report that the Licensee does not have systems in place to self-monitor the noted sections of the Residential Care Regulation (RCR) to ensure compliance. Failure to self-monitor for compliance with the legislation may increase risk to persons in care's health and safety, as their care needs may not be met. The Licensee will submit a Compliance Plan to Licensing by July 21, 2025 confirming that the non-compliance has been corrected and include the system that will be implemented for ongoing self monitoring of the physical environment, and the care and services provided to persons in care. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- 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 - The Licensee’s investigation determined that a nurse had not followed the facility’s policies and procedures for the management of missing medication, thus resulting in prescribed medications not being obtained or administered to the involved person in care for a minimum of two days. Licensing also noted these missed doses of prescribed medications while reviewing the Medication Administration Record during the investigation. Failure to administer prescribed medications could result in increased symptoms and complications from the conditions the medications are prescribed to manage. Contravention - The Licensee’s investigation determined that a nurse did not follow a person in care's skin and wound treatment plan resulting in missed skin and wound assessment and/or treatment. Failure to conduct skin and wound care assessments as required could result in worsening of skin conditions, thus increasing the risk to persons in care's health outcomes. The Licensee will submit a Compliance Plan to Licensing by July 21, 2025; medications will be administered as ordered, and skin and wound care assessments conducted as per treatment plans. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Contravention - The Licensee’s investigation determined that a nurse had contacted their supervisor due to prescribed medications not being available on site however, the prescribed medications were not obtained or administered during a two day period. Licensing also noted the missed doses of prescribed medications during a review of the Medication Administration Record thus it was found that the supervisor did not effectively manage this unusual situation. Failure of the supervising manager to effectively manage unusual situations could result in increased risk to persons in care due to missed care and/or required rapid responses to changing care needs. The Licensee will submit a Compliance Plan to Licensing by July 21, 2025 outlining how, when, and who will provide education to all current and future supervisors on the management of unusual situations. The Plan is to include a system for the ongoing monitoring of all future unusual situations to ensure they are managed effectively, and for sustained compliance
- 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)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Contravention - During Licensing’s investigation it was noted that documentation stated the involved person in care refused care on two occasions. There is no further documentation pertaining to these incidents, so it is unknown if re-attempts occurred or if care was eventually provided on those two occasions. If a person in care does not receive the care they require they are at increased risk for a decline in health and/or a loss of dignity. The Licensee will submit a Compliance Plan by July 21, 2025; the employees will meet the specific care needs of persons in care ensuring their health and dignity. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
- R10.2D - Ensure persons in care are not subjected to financial, emotional, physical, sexual abuse or neglect; 52( 1 )(a)
- 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): Contravention - During Licensing’s investigation it was noted that the care plan for the involved person in care did not contain directives for employees to manage responsive behaviours such as the refusal of care. Care plans are to contain all legislated requirements to help ensure that persons in care receive the care that is specific to their needs in order to mitigate risk of harm and ensure their health, safety, and dignity. The Licensee will submit a Compliance Plan by July 21, 2025; care plans for persons in care will contain all of the legislative requirements. The Plan is also required to outline who, how, and when the Plan will be monitored for sustained compliance.
- R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection
3 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Licensing Officer reviewed the most recent incident report submissions to Licensing. Of the previous twenty-six submissions, thirteen required additional information contrary to the Regulation.
- 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)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): Licensing Officer reviewed monthly weight records for three persons in care, all of which were not completed as per the Regulation.
- 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)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Licensing Officer observed the posted snack menu. The menu contained the same PM snack for multiple weeks. The menu also contained snacks that did not contain two food groups.
- 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)
- R5.1H - Provide a variety of foods in consideration of texture, colour, food safety, taste, and visual appeal; 62( 2 )(c)(iv)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Substantiated complaint
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Allegation – The Licensee is in non-compliance with Residential Care Regulation (RCR) 28(1). The allegation was investigated through information received from the complainant, the review of confidentially submitted documentation, a site visit, and correspondence with the licensee contacts. As a result, licensing found evidence that a person in care's bedroom did not have coverings to block light and potentially protect privacy. The allegation that the Licensee is in non-compliance with RCR 28(1) is substantiated.
- R7.1W- Each bedroom must have a window that provides natural light, with coverings to block light and protect privacy; 28 ( 1 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Routine Inspection
4 infractions
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): Licensing officer observed the documentation for restraint monitoring that was ineffective.
- R10.4C - 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)
- 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): Licensing officer observed two doors accessible to persons in care that were unlocked. This was contrary to facility policy. Licensing officer did not observe an orientation to the Regulation and the Act for all employees.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- 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): Licensing officer reviewed three staff files, two of which did not comply with the tuberculosis control programs.
- R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Licensing officer observed two sinks that were accessible by persons in care, both of which had temperatures that exceeded 49 degrees Celsius.
- R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- R10.4 - Are restraint and fall prevention plans appropriate?
- Substantiated complaint
1 infraction
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): It was confirmed during the inspection that medications were administered in a manner that did not meet Residential Care Regulation 70. Once this was determined, the Licensee took appropriate actions to mitigate future risk.
- R9.1E - Administer only medications prescribed or ordered by the medical or nurse practitioner; 70 ( 1 )
- R9.1 - Are medications stored, handled, and administered appropriately?
- Routine Inspection
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): Licensing Officer found a sign that was attached to a locked entrance door stating that social visits were suspended, this was contrary to facility policy. The sign was removed during the inspection. Comment: A unattended Spa door was unlocked during the inspection, contrary to facility policy.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(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?
- Routine Inspection
2 infractions
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): November 28, 2018 -It was noted that the Licensee does not have a monitoring system in place to ensure compliance with section 29(1). The persons in care's rooms that were audited did not include a safe, secure place to store valuables.
- R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 1 ) (a)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): November 28, 2018 -It was noted that the facility does not have a system in place to ensure that persons in care who temporarily leave the facility are in possession of written documentation stating their name, facility name, and emergency contact information.
- 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 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Monitoring
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): October 18, 2017 -It was noted that the facility did not have a system in place to ensure that laundry rooms not used by persons in care could not be accessed by persons in care. It was observed in one neighbourhood that a laundry room door was ajar, and reportedly the persons in care did not do their own laundry. It was observed in another neighbourhood that a laundry room door had been propped open. The manager reported that an educational notification would be sent out electronically to all employees immediately.
- R7.1AM - Ensure that laundry facilities if not used by persons in care, cannot be accessed by persons in care; 35( 2 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Monitoring
0 infractions
- Monitoring
8 infractions
- 2.2 Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): One person in care's care plan was missing written consent by the person in care or personal representative for the use of a restraint.
- 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)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): On medication administration records and in nurse progress notes, the reason and effectiveness for PRN (as needed) medication administration is not being recorded consistently.
- Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- 4.3 Is documentation concerning restraints adequate?
- Observation(s): One person in care's care plan identifies the monitoring of restraint is required each hour (with repositioning every 2 hours); however, no record of this monitoring was observed.
- 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)
- 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): It was noted that the care plans for persons in care are still in need of monitoring and review in order for the Licensee to ensure the person in care's needs are being met. Multiple person in care's care plans identify specific monitoring intervals for ongoing tray service provision, behaviours, restraints, and falls risks; however, no evidence is present to indicate this monitoring or reviews are being completed as directed (or required). This is a reoccurring infraction from the April 29, 2015 inspection report.
- Regularly monitor the physical environment and the care and services provided; 61
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): Multiple person in care's care plans were missing information which could be used to identify them in cases of emergency. Multiple person in care's care plans were missing written emergency consent to call a medical or nurse practitioner or ambulance in case of accident or illness.
- 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)
- 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): Activity room fridges contain undated, expired and unlabelled food items. The temperature monitoring and logging for the activity room fridges are also not being completed consistently.
- 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): Hot water temperature accessible to persons in care tested to exceed 49 degrees Celsius at many sources throughout the building. One damaged wall noted in one person in care's room (drywall gouched, chipped paint). Air fresheners (liquid and aerosol) stored in bathrooms are accessible to persons in care. Two pairs of sharp scissors observed to be stored accessible to persons in care (in person in care's bathroom). Medicated ointments observed on multiple bedside tables in person in care's rooms at the time of inspection. Director of Care removed these items at time of visit.
- Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- Ensure all medications are safely and securely stored; 69( 3 )(a)
- 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): No record indicating ongoing tray services being provided to persons in care are being reassessed by a medical or nurse practitioner as required.
- 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)
- 2.2 Are written policies and procedures in place to guide staff in fall prevention?