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Rosemont House

529 West Houston St Nelson BC V1L 6C9 · Residential Care - Licensing

7 inspections

  1. Routine Inspection

    3 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Two persons in care did not have record of TB screening or testing on file. Ensuring records are kept of persons in cares' TB screening/testing status, as outlined the Province's TB control program, works towards promoting the health and safety of persons in care. Submit by May 15, 2026, a written plan outlining how you will ensure all persons in care have evidence of compliance with the Province's TB control program on file. The plan must include the system you will implement to support ongoing monitoring to ensure sustained compliance.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Inspections have been completed for emergency lights, and fire suppression equipment. However, the most recent Fire Inspection from November 2025, noted a repair was needed to one of the sprinkler heads in the basement. This repair has yet to be completed. Ensuring repairs are completed to equipment as recommended by Fire Inspections is essential to ensuring emergency equipment is functioning in the event of a fire. Submit a written plan by May 15, 2026, confirming the repair or plans for the repair. The plan must include the system you will implement to support ongoing monitoring to ensure sustained compliance.
      • R7.1L - Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
    • 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): A person in care who had been screened as a risk to elope from the facility had an elopement care plan in place, however, it did not include a plan to locate the person in care. Ensuring a plan is in place to locate a person in care at risk of leaving without notifying an employee can help facilitate their safe return to the facility in a timely manner, thereby promoting their safety. At the time this report was written, the elopement care plan has been updated to include a plan to locate the person in the care. Submit by May 15, 2026, a written plan outlining how you will monitor elopement care plans to ensure they include all required information to ensure sustained compliance.
      • R10.3G - Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
  2. Routine Inspection

    3 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): The system in place to ensure that all persons in care have an updated immunization status on file appeared to be ineffective. In a review of records, licensing officer noted one person in care did not have any information recorded about their immunization status.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
      • R6.2B - Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): The washer and dryer are accessible by persons in care and licensing officer noted that there is not a non slip resistance surface in that area.
      • R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The current summer menu does not outline 3 food groups for each meal. Licensing officer observed some meals which included 3 food groups, but others contained just the protein or the meal type (i.e. vegetarian).
      • 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)
  3. Routine Inspection

    1 infraction

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): Licensing noted one person in care who has a consent for restraints in place, however, the type of restraint or nature for which it is to be used was not clearly outlined their care plan.
      • 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)
  4. Routine Inspection

    2 infractions

    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Although there was a menu in place, the breakfast and lunch menu were noted to contain options for the persons in care. There was no noted documentation of which option they were choosing or what was being consumed for breakfast or lunch. Staff explained what the typical snacks were and Licensing Officer noted them to meet the Canada Food Guide, however, there is not a snack menu, nor a record of what persons in care are consuming.
      • 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)
    • 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 that all care plans are reviewed or revised, at minimum, annually appeared ineffective. In a random audit of person in care records, licensing officer noted some documents used to guide care provision were outdated: -medication care plan -client’s daily routines -review of restraint documentation
      • 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. Monitoring

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): The system for ensuring that all medications are administered to person in care appears to be ineffective as evidenced by the the missing signatures on the PICS MARs.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(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): The medication policy in the MAR was not the same as the most current medication policy noted to be in the Policy binder.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): In a random audit of staffing files conducted on December 5, 2017, licensing noted that not all employees had an immunization status on file.
      • R3.1F - Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system for ensuring that all residents are weighed at least once per month appears to be ineffective. Of the files reviewed, one resident had missed two months and another had missed over 6 months.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
  6. Monitoring

    4 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): On medication administration records the 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)
    • 10.4 Are restraint and fall prevention plans appropriate?
      • Observation(s): Two persons in care who are at risk for falling have falls prevention plans in place which have not been updated since April 2014.
      • Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (Show More)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Date of admission on the person in care's care plans could not be located.
      • Keep for each person a record showing the date of admission to the facility; 78( 1 )(b)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): A small amount of mildew was observed in the grout lines and seams along the floor and in the bottom corners of the shower.
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
  7. Monitoring

    3 infractions

    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): One resident was noted to be missing TB screening documentation. CORRECTION DATE: FEBRUARY 20, 2015.
      • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 (15)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The flooring in the kitchen was noted to be "lifting" in some areas and there is an actual "bump" on the floor by the medication cupboard which could contribute to trips/falls. Please provide a plan to licensing by MARCH 31, 2015 as to when/how the repair will occur. CORRECTION DATE: MARCH 31, 2015.
      • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
    • 10.3 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 Pivot Point Care plans stated their review date was to be December of 2014. If this is not when the plans were due for review, please ensure the correct review date is indicated. CORRECTION DATE: FEBRUARY 20, 2015. The Health Care Plans (yellow folders) are due for review. CORRECTION DATE FEBRUARY 20, 2015. The Nutrition care plan and the Health Care Plan refer staff to the resident's "Mealtime Guidelines" - these guidelines have not been regularly reviewed. One dated 2013 another dated 2007. CORRECTION DATE FEBRUARY 20, 2015.
      • 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)