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Mission Creek Landing Ltd.

3081 Hall Rd Kelowna BC V1W 2R5 · Residential Care - Licensing

7 inspections

  1. Routine Inspection

    2 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): March 4, 2026 The Licensee does not have a system in place to ensure allegations of abuse are reported to Licensing immediately. An allegation of abuse occurred but was not reported to Licensing until five days later. When allegations of abuse are not reported to Licensing immediately, Licensing is unable to immediately assess level of risk to persons in care and/or determine appropriate follow up to ensure their health, safety and dignity. The Licensee is to submit a Compliance Plan by March 25, 2026, outlining the system that will be put into place to ensure all alleged or suspected incidents of emotional, physical, financial, sexual abuse or neglect are immediately reported to Licensing. The Licensee does not have a system in place to ensure reportable incidents are reported in compliance with the legislation. Multiple submissions have been incomplete and required follow up. When reportable incidents are incomplete, Licensing is unable to assess level of risk to persons in care and/or determine appropriate follow up to ensure their health, safety and dignity. The Licensee is to submit a Compliance Plan by March 25, 2026, outlining the system that will be put into place to ensure that reportable incidents are submitted in compliance with the legislation.
      • R4.5C - Report when a person in care is the subject of emotional, physical, financial or sexual abuse or neglect; 77(1)(a)(ii)
      • R4.5G - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(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): March 4, 2026 The Licensee does not have a system in place to ensure that Care Plan and My Day documentation contain the same directives. Five Care Plans reviewed and the following is observed: high falls risk in Care Plan, not documented on My Day for two persons in care; co-sleeping plan in Care Plan, not documented on My Day; elopement risk in Care Plan, not documented on My Day. When Care Plan and My Day directives are not in alignment, there is risk of persons in care not receiving their required care which may negatively impact their health, safety and/or dignity. The Licensee is to submit a Compliance Plan by March 25, 2026, outlining the system that will be put into place to ensure all Care Plans and My Days for each person in care contain the same directives. The Licensee does not have a system in place to ensure that employees implement and/or document responsive behaviour Care Plan directives. When reviewing a medication administration record (MAR), it is observed that PRN (as needed) medication had been administered for responsive behaviours with no documented evidence that Care Plan directives had been implemented prior to using the PRN medication. When the care and supervision that persons in care receive is not in alignment with the directives in their Care Plan, there is risk of negative health, safety and/or dignity outcomes. The Licensee is to submit a Compliance Plan by March 25, 2026, outlining the system that will be put into place to ensure that the implementation of a person in care’s Care Plan and documentation is consistent with the directives in the Care Plan.
      • 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)
      • 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. Substantiated complaint

    1 infraction

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Allegation – the Licensee is in non-compliance with RCR 12(2) - If requested by a medical health officer, a licensee who is being investigated must provide to the medical health officer a plan to ensure the health and safety of persons in care during the investigation. Reportedly, a Health and Safety Plan (H&S Plan) approved by Licensing during an investigation was not followed by the Licensee. The Licensing Officer followed up on the allegation, and the Licensee confirmed that the H&S Plan was not followed; therefore, the allegation of non-compliance with RCR 12(2) is substantiated.
      • R1.1S - Provide a plan to ensure health and safety of persons in care during an investigation; 12 ( 2 )
  3. Routine Inspection

    0 infractions

  4. 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 does not have a system in place to ensure that all facility policies regarding medication documentation are implemented by employees, and that the policies regarding required documentation on My Days are implemented. Contravention - During an Electronic Medication Administration Record (E-MAR), progress notes, and care plan audit for persons in care, it was noted that congruent to facility policy, some medications that are administered as needed (PRN) were not documented in the E-MAR system and the effectiveness of medication PRN's were also not documented in the E-MAR system in a timely fashion; some were data entered into the E-MAR days after the PRN was administered. Contravention - During a Care Plan and My Day audit of two persons in care, both had the directive to conduct a head-to-toe assessment documented in their Care Plan, but only one had it documented in their My Day. During the inspection, the leadership team identified that this was not following facility policy. Comment - The My Days that were audited by Licensing contained different update dates from their corresponding Care Plans. A member of the Leadership team reported that the My Days had been updated at the same time as the Care Plan. The Leadership team stated that moving forward a system is being put into place to ensure the dates are auto-populated when the My Days are updated.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • 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 Licensee does not have a system in place to ensure all elements of the oral health care plan are in place, nor is there a system to ensure that the supervision of persons in care is consistent with the terms and conditions of the person's care plan. Contravention - During a Care Plan audit of three persons in care, two had their care plan directing staff to review the My Day for an oral health care plan, however the two My Day's did not contain an oral health care plan. Contravention - During a Care Plan audit of three persons in care, there were inconsistencies noted for two of them between the Care Plan and My Days. One My day was missing instructions to use grip socks which was a falls risk issue. The other was missing a waking time which was important for health related reasons.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
      • 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
  5. Routine Inspection

    8 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): June 25, 2019 3.) The facility does not have a system in place for ensuring that all of the legislated requirements are in place in the records of the persons in care. During a chart and care plan audit for a person in care who is using a restraint it was noted that there was not a signed, written agreement in place from the person in care or their representative.
      • R2.2A - 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)
    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): June 25, 2019 5.) The facility does not have a system in place for ensuring that all of the legislated requirements are in place in the records of the persons in care. During a chart and care plan audit for a person in care who is using a restraint it was noted that multiple sections of the legislation for restraint implementation and monitoring were missing.
      • R4.3A - Record the type or nature of the restraint used in the person's care plan; 84(a)
      • R4.3B - Record the reason for the use of restraint in the person's care plan; 84(b)
      • R4.3C - Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
      • 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)
      • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): June 25, 2019 8.) The facility does not have a system in place for ensuring that all of the legislated requirements are in place in the records of the persons in care. During a chart and care plan audit for a person in care who is using a restraint it was noted that documentation for monitoring was missing.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): June 25, 2019 1.) The Licensee does not have a system in place to regularly monitor the physical environment and the care and services provided to ensure compliance with the Regulation and Act as noted in the contraventions in this report.
      • 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): June 25, 2019 2.) Outstanding from the December 4, 2018 Routine Inspection: A Compliance Plan had been put into place to ensure that all staff and new hires were orientated to the Residential Care Regulation by February 1, 2019. During the inspection it appeared that the Plan had not been followed and no documented evidence could be located to indicate that the Plan had been followed. The Manager reported that a Plan will be put into place to have all staff orientated to the Regulation by the middle of July, and those staff who are on leave will be orientated upon their return. The facility's emergency evacuation plan was reviewed including an upcoming evacuation drill, evacuation sites, the plan for evacuation assistance, an alternate evacuation exit road from the facility, and the provision of continuing care.
      • 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): June 25, 2019 4.) The facility does not have a system in place for ensuring that all of the legislated requirements are in place in the records of the persons in care. During a chart audit it was noted that immunization screening could not be located. The Manager reported that a plan will be put into place to ensure that immunization screening is conducted for all persons in care along with the annual influenza and pneumococcal screening. Email notification will be sent to representatives, and the screening will commence in September.
      • R4.1C - Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78( 1 )(a) Director of Licensing Standards of Practice: Immunization records
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): June 25, 2019 6.) The facility's system for ensuring that all common areas are in a good state of repair was noted to be ineffective. An area of the gazebo was noted to have rotting, split wood with sharp areas and two nails protruding. An immediate Health and Safety Plan was requested to be submitted as to how the Licensee would ensure the person in care's safety during the time period from June 25, 2019 until the planned removal of the gazebo.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(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): June 25, 2019 7.) The facility does not have a system in place to ensure that all persons in care have a current care plan that addresses their unique needs and preferences. During a chart audit it was identified that one person in care had a behaviour care plan in place however there was no general care plan to address activities of daily living, transfers, and other aspects of assessment, care providing, and directives. It was discussed that the Compliance Plan is to identify how many persons in care do not have a current care plan, the date that the care plans will be completed by for the high risk persons in care such as responsive behaviours, falls, wound care, restraints, and in-room meal service, the date that the remaining care plans will be reviewed and completed by, and a detailed plan for maintaining ongoing compliance.
      • 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)
  6. Routine Inspection

    7 infractions

    • RB1.5 - Are persons in care informed on how to express concerns or make complaints to the medical health officer or to the Patient Care Quality Office prior to admission?
      • Observation(s): Please see report.
    • RB1.17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
      • Observation(s): Please see report.
      • RB1.17A - Post the most recent routine inspection in a prominent place.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): December 4, 2018 The facility does not have a system in place to ensure that the most recent routine inspection report is posted. The most recent routine inspection report was noted to not be posted at the time of inspection. Please submit a Compliance Plan that outlines who is responsible for posting the most recent routine inspection report, and who will audit the Plan to ensure that the report remains posted.
      • 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)
    • 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): December 4, 2018 OUTSTANDING from a previous inspection: The contact number for Licensing that is provided to persons in care and their representatives in a handbook is incorrect. The facility does not have a system in place to ensure that new managers and employees are orientated to the Regulations and the Act. Please submit a Compliance Plan that outlines the date that the Licensing contact number will be corrected in the handbook, and how and by what date the updated handbook will be disseminated to all persons in care and their representatives. Please submit a Compliance Plan that outlines how and by what date all staff will be orientated to the Residential Care Regulation, and what system will be put into place to ensure that moving forward all new hires are orientated to the Regulation.
      • R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
      • 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): December 4, 2018 The facility does not have a system in place to ensure that written consent to call a medical nurse or practitioner or ambulance in case of accident or illness can be located in all persons in care's charts.
      • R4.1I - 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): December 4, 2018 The facility does not have a system in place to ensure the safe storing and handling of food in personal refrigerators. Please submit a Compliance Plan outlining the system that will be put into place to ensure the safe storage of food in personal refrigerators, and who will conduct monitoring and when to ensure ongoing compliance.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 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): December 4, 2018 The facility does not have a system in place to ensure that the "My Day" section of the care plan is updated at least once a year. An audit of one room showed that the care plan was dated as having been reviewed in September 2017. Please submit a Compliance Plan outlining the system that will be put into place to ensure that all persons in care's care plans are modified with a substantial change or at least once a year, and who will be responsible for the monitoring and how to ensure ongoing compliance.
      • 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)
  7. Monitoring

    2 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): April 11, 2018 -It was noted that the manager's name was not posted. This was corrected during the inspection. -It was noted that the facility did not have a system in place for monitoring the physical environment to ensure that the temperature of the water that was accessible to persons in care did not exceed 49 degrees Celsius. -It was noted that the facility did not have a system in place for monitoring to ensure that an infraction noted on the initial monitoring inspection had been resolved.
      • R1.1N - Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): April 11, 2018 -It was noted that the facility did not have a system in place to ensure that the temperature of water that was accessible to persons in care did not exceed 49 degrees Celsius. Water temperature measured on three neighbourhoods registered from 51.0 to 56.7 degrees Celsius. The facility put an immediate Health and Safety Plan into place. The hot water was turned off in the resident's rooms, and maintenance returned to the facility to regulate the temperature. OUTSTANDING from the initial inspection September 6, 2017 -Resident's rooms were audited and not all rooms contain a safe, secure place in which the person in care may store valuable property.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 1 ) (a)