Monashee Mews
2165 Norris Ave Lumby BC V0E 2G0 · Residential Care - Licensing
7 inspections
- Routine Inspection Follow-up
2 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Licensing received an incident report on March 26, 2026 regarding the abuse allegations that were made February 23, 2026. Licensing was not made aware of the allegations or the health and safety plan until more than a month after the events. Failing to notify Licensing as required prevents Licensing to ensure that there is oversight regarding potential risks to health and safety and to also determine whether there needs to be Licensing involvement in the incident review and investigation. This also reduces Licensing's confidence in the licensee to voluntarily comply with the legislation. Submit by April 23, 2026 a plan to ensure that all levels of the organization understand the reporting requirements, and provide a system to ensure these requirements are complied with.
- 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)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): The investigation determined that persons in care were subjected to harmful actions by the the involved staff who failed to meet the care needs of persons in care. Failing to meet the care needs of a person in care is defined as neglect in the Residential Care Regulation. Submit by April 23, 2026 evidence that the licensee has taken steps to ensure that persons in care are not subjected to harmful actions.
- R10.2D - Ensure persons in care are not subjected to financial, emotional, physical, sexual abuse or neglect; 52( 1 )(a)
- R4.5 - Are incidents and notifications reported and records retained as required?
- 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): While the facility has emergency plans in place, the plan is not displayed in a prominent place.
- R2.1I - Display a copy of the emergency plan in a prominent place; 51 ( 4 )
- 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
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Performance assessments have not been completed annually as required. New manager is in process of getting these completed.
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Water temperature in resident rooms throughout the facility exceeded 56 degrees. The temperature was brought into compliance during the inspection, and the licensee contact will provide a plan for ongoing monitoring.
- R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Routine Inspection
5 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): TAR administration was not consistently recorded in TAR record.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
- Observation(s): A review of the calendar of activities and a discussion with staff indicated that planned staff-directed activities were only available for PICs on four days a week.
- R8.1A - Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55( 1 )(a)(i)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Most recent routine inspection report was not displayed.
- 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): PIC Diet and meal preferences list displayed in serveries had not been updated. Process regarding updating sheets was not followed.
- 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): Licensing reviewed a sample of care plans and related documentation. The following was observed: Some activity of daily living (ADL) documents, which guide the care and supervision of persons in care, did not reflect the care plans. For example, One ADL documented a TAR ointment which had been discontinued. The ADL was dated November 2022. Another ADL failed to document a smoking plan. *This is a repeated contravention from the last inspection.
- R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Substantiated complaint
2 infractions
- R4.6 - Are facility records current and complete?
- Observation(s): As a result of the complaint investigation, Licensing notes discrepancies within recreation documentation of programming offered and participation.
- R4.6L - Ensure all records are current; 91( 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): The complainant alleges non-compliance with care plan monitoring to ensure proper implementation, specifically in regards to nutrition restrictions and use of oxygen. Licensing reviewed care plans, dysphagia assessments, progress notes, Dietician correspondence and Physician assessment. Licensing notes is appears nutrition and oxygen care plans have been monitored for proper implementation, however, recreation care plans have not been. Licensing reviewed recreation care plans and activity tracking records and notes the programming, offered to a person in care, does not align to with the type of activities or frequencies as directed within the care plan. The system in place to monitor the proper implementation of care plans is ineffective. Licensing determines this complaint to be SUBSTANTIATED. The complainant alleges non-compliance with the implementation of care plans, specifically that a person in care is taken out in a wheelchair by Physiotherapy (PT) but is not provided PT. Licensing reviewed care plans and PT progress notes. Licensing notes that a person in care is taken out in a wheelchair offsite, however, a care plan for this activity has not been developed nor has an assessment been conducted by PT. Licensing determines this complaint to be SUBSTANTIATED.
- R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
- 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
- R4.6 - Are facility records current and complete?
- Substantiated complaint
2 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): During the investigation of the allegations, Licensing noted the person in care related to the complaint had been involved in a reportable incident. Licensing and the funding program were not notified. These contraventions were resolved prior to the completion of this report.
- 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)
- R4.5E - Immediately notify the funding program, if any, if a person in care is involved in a reportable incident; 77( 2 )(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 complainant alleges non-compliance with the implementation of a person in care's medication administration and circulatory system care plans. In discussions with the Licensee and a review of facility records, Licensing confirmed two instances where medication administration did not follow the doctor's orders and found no evidence of the implementation of the circulatory care plan. Licensing determines this complaint to be SUBSTANTIATED.
- 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
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
4 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Upon review of the last Medication Safety and Advisory Committee meeting, Licensing noted a service delivery problem involving misplaced medication. The incident report was submitted to Licensing prior to the completion of this report.
- 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): The system that is in place for ensuring employees implement the facility's policies and procedures is ineffective. Licensing noted completion of some post fall neurovitals were not conducted as per facility policy. The system in place for completion of assessments and reviews is ineffective. Licensing observed a suicide risk assessment, recreation assessments and aggressive alert reviews not always completed as scheduled as per policy.
- 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): Licensing reviewed a sample of employee records. Employees hired since the change of licensee obtained RCMP vulnerable sector criminal record checks prior to employment. Please ensure all employees obtain clear criminal records checks under the Criminal Record Review Act.
- R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 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): Licensing reviewed a sample of care plans and related documentation. The following was observed: 1) Some activity of daily living (ADL) documents, which guide the care and supervision of persons in care, did not reflect the care plans. One ADL documented a restraint when the person in care did not have a restraint. One did not document fall precautions in place as in the care plan. 2) The system in place to monitor the wound care plan is ineffective. Documentation of assessment and treatment is inconsistent.
- R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
- R4.5 - Are incidents and notifications reported and records retained as required?