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Nelson Avenue Residence

620 Nelson Ave Nelson BC V1L 2N6 · Residential Care - Licensing

5 inspections

  1. Routine Inspection

    2 infractions

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Medication administration records (MARs) were reviewed. In one MAR, there is no effectiveness documented for medications administered as needed (PRN). Not documenting PRN effectiveness may increase the risk to the persons in care as thy may not receive their as needed medications in a manner that meets their needs. Submit by June 12, 2026, a written plan outlining how you will ensure the effectiveness is recorded for all medications administered on an as needed basis. The plan must include the system you will implement to support ongoing monitoring to ensure sustained compliance.
      • R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • 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 explained how a person in care takes a specific medication, however, the process staff follow is not outlined in a medication care plan. Without a current care plan stipulating how a person in care takes their medications, there is a risk that staff may not administer medications to meet the needs of persons in care. Submit by June 12, 2026, a written plan outlining how you will ensure that all persons in care have a medication care plan. The plan must include the system you will implement to support ongoing monitoring to ensure sustained compliance.
      • R10.3B - Care plans must include a plan to address medication, including self-medication; 81( 3 )(a)(i)
  2. Routine Inspection

    1 infraction

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system for ensuring emergency drills are done as per policy was ineffective as it was noted that there was not a monthly drill conducted in June of 2024.
      • R3.1Z - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
  3. Routine Inspection

    1 infraction

    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The licensee showed evidence of regularly scheduled inspections for all emergency equipment. However, one item noted from the last inspection of fire safety equipment had not yet been addressed. Licensing confirmed that the alarm system is functioning despite the need to replace a part.
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
  4. Routine Inspection

    3 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): In review of previous fire safety inspections, it was noted that when a certain door was closed, the emergency lighting did not illuminate a hallway leading to an exit. The licensee had submitted a work order to address this, however, it has not yet been completed.
      • R7.2K - Ensure a facility having less than 7 persons in care has emergency lighting for hallways and stairs must automatically illuminate for at least 30 minutes in the event of a power failure; 20(c)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The system for ensuring the menu provides meals with three food groups from the Canada Food Guide and snacks from two food groups from the Canada Food Guide appeared ineffective. The meal menu indicates some meals as leftovers or sandwiches but there is no information pertaining to what food groups were included in the sandwich or leftovers. Although there was evidence of snacks being provided, there is not a snack menu or evidence of the snacks consisting of two food groups.
      • R5.1C - Provide for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups described in Canada's Food Guide; 62( 2 )(a)
      • 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)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system for ensuring the food is safely stored appeared ineffective. There is no evidence of fridge temperatures being monitored to ensure that food is safely stored.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  5. Routine Inspection

    2 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The system to ensure that all persons admitted to the facility comply with the Province's immunization and TB control programs appeared ineffective. A resident residing in the facility since February 2019, did not have any record of immunization status or TB screening.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 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 system for ensuring all care plans are reviewed/revised, at minimum annually appeared to be ineffective. LO was unable to ascertain if some documents describing methods of care provision were current as they were not dated: medications and safety, communication, and personal care.
      • 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)