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Mount Nelson Place A

750 6th Avenue Invermere BC V0A 1K0 · Residential Care - Licensing

8 inspections

  1. Routine Inspection

    4 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): R4.5G - During a review of minor incident records, a reportable incident is identified that is not reported in accordance with legislative requirements. The current system for reviewing minor incident records does not include a review of Schedule D to ensure reportable incidents are identified and submitted as required. Failure to identify and report reportable incidents in a timely manner poses a risk to the health, safety, and well‑being of individuals receiving care. Submit by May 4, 2026, a written plan outlining how the contravention related to ensuring reportable incidents are submitted as required has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 77(2)(c) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): R1.1W - Based on a review of documentation, the system currently in place to ensure monitoring and compliance is ineffective. Specifically: -Monthly weights are not consistently completed as required. -There is no documented evidence of ongoing monitoring to ensure annual consents and agreements are completed in accordance with licensee policy. -There is no documented evidence of current audits and/or monitoring, or of follow‑up actions taken when a self‑identified deficiency is identified. Inconsistent monitoring and oversight increases the risk that community care services are not delivered consistently, safely, or in accordance with licensing requirements. Without regular monitoring, deficiencies may go undetected, required standards of care may not be maintained, and corrective actions may not be taken in a timely manner, potentially placing individuals at risk of harm and resulting in non‑compliance with the Community Care and Assisted Living Act and associated regulations. Submit by May 4, 2026, a written plan outlining how the contravention related to ensuring the care and services provided is regularly monitored has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 61 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): R4.1V - A document containing personal information related to the care needs of persons in care is posted in a bathroom that is accessible to all persons in care, as well as family members and visitors. The document is removed during this inspection. The posting of personal information in a publicly accessible area poses a risk to the privacy and confidentiality of persons in care. Submit by May 4, 2026, a written plan outlining how the contravention related to ensuring records and personal information of persons in care is kept confidential has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 93 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R4.1V - Keep the records and personal information of persons in care confidential to the greatest extent possible while maintaining the health, safety and dignity of persons in care; 93
    • R4.6 - Are facility records current and complete?
      • Observation(s): R4.6Q - Persons in care daily financial records and petty cash are stored at another licensed site and are accessible to employees who do not require access to perform their duties. This presents a risk of unauthorized access, loss, or misuse of personal and financial information belonging to persons in care. Submit by May 4, 2026, a written plan outlining how the contravention related to ensuring records related to persons in care are accessible only to employees who require access has been addressed. The plan must also describe the system and processes that will be implemented to support the ongoing monitoring of Section 91(3)of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • R4.6Q - Ensure records related to a person in care are accessible only to employees who require access to perform their duties in relation to the person; 91 ( 3 )
  2. Routine Inspection

    4 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): During a review of a person in care's restraint documentation, it was noted that documentation was incomplete. Multiple days contained missing signatures, with no corresponding notes to indicate that the person in care may not have been in the restraint. Multiple days were also noted to be missing from the records. The use of a restraint without consistent monitoring increases the risk to the person in care's physical safety and emotional dignity. Submit by April 24, 2025, the plan that will be implemented to ensure ongoing compliance with Section 84(d) of the Residential Care Regulation.
      • 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)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): During a review of the monthly menu, it was noted that the menu did not include 2 nutritious snacks with at least 2 food groups daily. The absence of nutritious snacks containing at least 2 food groups increases the risk to the person in care's nutritional health and overall well-being. Submit by April 24, 2025, the plan that will be implemented to ensure ongoing compliance with Section 62(2)(b) of the Residential Care Regulation.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): During the inspection of the physical facility, a can of household paint was located in the bottom of a closet that is accessible to persons in care. Access to household paint poses several risks to persons in care, especially those who may have cognitive impairments, mental health challenges, or other vulnerabilities. This contravention was corrected during the inspection. The Manager relocated the paint to the locked basement area of the facility, which is not accessible to persons in care. Submit by April 24, 2025, the plan that will be implemented to ensure ongoing compliance with Section 35(1)(c) of the Residential Care Regulation.
      • 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): During a review of 4 person in care's care plans, it was noted that care plans did not include a plan to address medication. It was confirmed by the Manager, that no persons in care self-administer any medication. When persons in care do not have a medication care plan, risks can arise that may negatively impact their health, safety, and overall well-being. Submit by April 24, 2025, the plan that will be implemented to ensure ongoing compliance with Section 84(3)(a)(i) of the Residential Care Regulation.
      • R10.3B - Care plans must include a plan to address medication, including self-medication; 81( 3 )(a)(i)
  3. Routine Inspection

    4 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): It was identified during the inspection that laundry facilities accessible to persons in care did not have a slip resistant floor surface.
      • R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
    • RB1.23 - Do care plans take into account the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences?
      • Observation(s): The licensee does not currently have a system in place to ensure persons in care who leave the facility independently have a plan in place.
      • RB1.23A - Ensure the person in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences are taken into account in their care plan.
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): It was identified during the inspection that the system in place to monitor fridge and freezer temperatures to ensure safe storage of food is ineffective. It was identified during the inspection that temperatures were not recorded as required.
      • 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): The licensee does not currently have a system in place to ensure persons in care who leave the facility independently have a plan in place.
      • 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)
  4. Routine Inspection

    6 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system to ensure the medication administration records are accurate and complete showing the date, amount, and time a medication was administered is ineffective. A person in care's medication administration record was noted to have multiple medications not recorded as being given as prescribed.
      • 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): The system to ensure restraint monitoring is completed is ineffective. Upon review of the restraint documentation in a person in care's records, it was noted to be inconsistently recorded.
      • 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)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The system for self-monitoring the care and services provided is ineffective as noted by the contraventions identified in this report.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system to ensure as needed medication (PRNs) effectiveness is noted is ineffective. During a review of the medication administration records for a person in care, it was identified that the effectiveness of as needed medications given, had not been recorded.
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): The system to ensure a pharmacist records all medications on the person in care's medication administration record is ineffective. A person in care's medication administration record was noted to have a handwritten medication added to the record.
      • R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(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): The system to ensure person in care's care plans are reviewed, and modified if necessary, at least once a year is ineffective. It was noted that multiple persons in care did not have a documented care plan review, and/or revision within the last year.
      • 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)
  5. Routine Inspection

    1 infraction

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): It was noted during the inspection that there is not currently a system in place to monitor restraints. It was noted that the system for ensuring restraint re-assessments are up to date appeared ineffective.
      • 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)
  6. Routine Inspection

    0 infractions

  7. Monitoring

    3 infractions

    • 7.2 Is the environment maintained to prevent falls?
      • Observation(s): Licensing observed loose carpeting in main living area that could potentially be a tripping hazard.
      • Ensure furniture and equipment for use by persons in care are maintained in a good state of repair; 21(c)
      • Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
    • 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): Licensing observed loose carpeting in main living area that could potentially be a tripping hazard. Licensing noted bathroom with tub in lower area had chipped paint and and scuffed walls. The upper bathroom has screw holes that have not been addressed.
      • Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing noted bathroom with tub in lower area had chipped paint and and scuffed walls. The upper bathroom has screw holes that have not been addressed.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
  8. Monitoring

    5 infractions

    • 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): Complaints information does not include PCQO role or contact information.
      • 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)
    • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Snacks offered do not consistently include items from 2 food groups.
      • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Food freezer temperature is not monitored and no thermometer is present.
      • 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): Shed in back yard not locked, contains chemicals and sharp tools. Fence is separating at top rail in one corner of yard.
      • 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 the outside activity area is secured by a fence or other means, if necessary to protect the health and safety of persons in care; 36 ( 2 )
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Persons in care leaving the facility do not routinely carry identification.
      • 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 )