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Kimberley Special Care Home

386 2 Ave Kimberley BC V1A 2Z6 · Residential Care - Licensing

11 inspections

  1. Routine Inspection

    2 infractions

    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): During a review of the physical facility, it was identified that on three separate dates, fridge temperatures were recorded outside of the required range. There was no documented evidence to confirm that the follow-up steps as outlined on the tracking form to correct the temperatures had been completed. This poses a potential risk to the safety and quality of stored food, which may impact the health and well-being of persons in care. Submit by September 26, 2025, a written plan outlining how the contravention related to ensuring food is safely stored has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 63(1) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • 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): During a review of wound care plans and records, it was identified that one would care plan was not followed as written. The documented care completed did not align with the frequency outlined in the care plan. This poses a potential risk to the health and safety of the person in care. Submit by September 26, 2025, a written plan outlining how the contravention related to ensuring that the care and supervision is consistent with the terms of the care plan has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 82 of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
      • 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. Routine Inspection

    2 infractions

    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system to monitor the health and safety of each person in care on a regular basis to determine if their needs continue to be met is ineffective. This Licensing Officer reviewed multiple person in care's charts. It was noted that a person in care's progress notes referenced bed positioning equipment being used incorrectly. There was no documented evidence of the equipment in the care plan plan, or follow up to monitor if the person in cares needs continue to be met. It was noted that information from allied health professionals (physiotherapy, occupational therapy, dietician) assessments is not consistently being added to care plans and 'My Day' plans. This is a re-occurring contravention from the November 2023 inspection.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 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 to ensure care plans are reviewed, and modified if necessary is ineffective. This Licensing Officer reviewed multiple random charts. It was noted that a person in care's care plan, and 'My Day' did not contain updated information regarding current equipment. The care plan was noted to have been reviewed within the past year; however, did not contain current information regarding a tray on a wheelchair. A second care plan was noted to not have an updated nutritional care plan regarding tray service.
      • 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)
  3. Routine Inspection Follow-up

    0 infractions

  4. Routine Inspection

    7 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): The system to ensure restraint monitoring is completed is ineffective. During a review of resident charts it was noted that restraint monitoring documentation was inconsistently completed.
      • 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 current system in place for ensuring ongoing compliance is ineffective as evidenced by the number of new, and re-occurring contraventions identified within 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): The system to ensure policies are implemented by employees is ineffective. Through a random chart audit, observations and discussion with staff, and a review of various documentation on site, it was noted that the Least Restraint policy is not being implemented by employees.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system to ensure each person in care has their monthly weight recorded is ineffective. This is a re-occurring contravention from the May 2022 inspection.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system to ensure hazardous materials are not accessible to persons in care is ineffective. A door with clear signage to be locked, was found unlocked, with open cleaning agents, and accessible to persons in care. This contravention was corrected during the inspection.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The system to monitor the health and safety of each person in care on a regular basis to determine if their needs continue to be met is ineffective. During a random chart review there was no evidence that recommendations from both Dietician, and Physiotherapist assessments were reviewed, implemented and/or added to the person in care's care plan. There was also no evidence of a smoking assessment being completed as referenced in a person in care's care plan.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 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 to ensure care plans address the unique abilities of persons in care is ineffective. A smoking care plan did not contain any unique abilities of the person in care.
      • 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)
  5. Routine Inspection

    7 infractions

    • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
      • Observation(s): The system to ensure person in care are encouraged to participate in program of activities was ineffective. A review of the Recreation Attendance Records in a persons care plan were only marked with an 'A' (Active) sporadically. There is no evidence to suggest the person in care was encouraged or declined.
      • R8.1B - Encourage persons in care to participate in the program of activities provided (Does not apply to Hospice); 55( 1 )(b)(i)
    • RB1.15 - Are persons in care encouraged to participate in the facility's program of activities and to take advantage of opportunities available in the community?
      • Observation(s): The system to ensure person in care are encouraged to participate in program of activities was ineffective. A review of the Recreation Attendance Records in a persons care plan were only marked with an 'A' (Active) sporadically. There is no evidence to suggest the person in care was encouraged or declined.
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The system to monitor secure doors is ineffective. A door with clear signage to be locked, was found unlocked and accessible to persons in care . This infraction was noted on the previous inspection in May 2022. The system to monitor fridge temperatures is ineffective. It was noted on several fridges that the past three days, no fridge temperatures had been recorded.
      • 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): The system to ensure that emergency exits are not obstructed was ineffective. Licensing observed an emergency exit obstructed by a large bin.
      • R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Handwritten labels noted in medication administration records.
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Oral Care Plans were lacking a specific plan, no evidence to suggest person in care was examined by a dental health care professional in the past year or any pending appointment.
      • R10.2H - Encourage persons in care to be examined by a dental health care professional at least once every year; 54( 3 )(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 system to ensure there is a plan for persons at risk of leaving the facility is ineffective. Persons in care identified as an elopement risk did not have a care plan. The auditing system to review and, if necessary, modify a care plan is ineffective. It was noted that a 'Recreation Assessment - initial' was completed in May 2019 with no annual assessment since.
      • 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)
      • 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

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The system to monitor secure doors is ineffective. A door with clear signage to be locked, was found unlocked and accessible to persons in care.
      • 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): The system to ensure policies are implemented by staff was ineffective. It was noted that staff were not completing Falls Risks as per policy. This was also identified by the nurse in charge. A new system is currently being developed and implemented.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The system to ensure the height and weight of each person in care is recorded on admission was ineffective. Upon a random chart audit it was identified that multiple charts did not have record of height and weight on admission. The system to ensure each person in care has their weight recorded monthly was ineffective. It was identified that the monthly weights recorded in the person in care's chart were inconsistent.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • 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)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There was no evident system to obtain written authorization for release of persons in care. This infraction was noted on the previous inspection in October 2021. The system to ensure ongoing room tray service is reassessed at least every 30 days is ineffective. Licensee is currently working on developing a new system for reassessing ongoing tray service.
      • R10.2Q - Only a parent or representative or a person authorized in writing by that person can release or remove a person in care from the facility; 58( 1 )(a)(b)
      • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
  7. Substantiated complaint

    3 infractions

    • R8.2 - Does the program of activities support individualized care plan requirements?
      • Observation(s): Contravention arising from the investigation: The licensee has a system in place to track program of activities. Upon review of recent months records for the person in care, the evidence did not indicate ongoing planned activities to meet the objectives of the persons care plan.
      • R8.2A - Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55( 1 )(a)(ii)
    • 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): Contravention arising from the investigation: The licensee was noted to provide prompt responses to the family representative; however, the noted responses did not address all concerns that were identified.
      • R2.1L - Respond to all complaints, concerns, disputes promptly. 60(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): The licensee was unable to provide evidence of hourly checks as per the revised care plan, therefore, the allegation is 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
  8. Routine Inspection

    8 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): It was noted during the inspection that the system for ensuring restraint agreements are complete was ineffective.
      • 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): It was noted during the inspection that the system for ensuring the ongoing monitoring of restraints was ineffective. Restraint monitoring was inconsistently documented.
      • 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): It was noted during the inspection that the most recent inspection report was not displayed. This contravention was corrected during the inspection. During the inspection multiple doors to secure areas, were noted to be unlocked. This contravention was corrected during the inspection.
      • 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)
      • 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): The system for ensuring post falls policies are implemented by employees appeared ineffective. Post fall monitoring was noted to be missing or incomplete.
      • 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): As needed medication (PRNs) effectiveness was noted to be inconsistently documented.
      • R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): During the inspection it was noted common areas, and multiple bedrooms in poor state of repair. Chipped paint, large scratches in walls, missing trim and tape used to repair walls were all noted during inspection. Please inform licensing of the plan and systems put in place to ensure damaged surfaces are repaired, and ongoing maintenance is completed to ensure dignity of person in care.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): It was noted during the inspection that the system for ensuring each person in care had authorized in writing, the representatives authorized for release or removal of a person in care from the facility was ineffective. During random chart audit written authorization was not noted on any of the charts.
      • R10.2Q - Only a parent or representative or a person authorized in writing by that person can release or remove a person in care from the facility; 58( 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): During the inspection it was noted that there is currently no system in place for ensuring the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan.
      • 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
  9. Routine Inspection

    7 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): During inspection it was noted that the system for obtaining restraint consent was ineffective.
      • 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)
    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): PRN effectiveness noted to be inconsistently documented. Treatment Administration Records were noted to be inconsistently documented and did not follow Medication Safety Advisory Committee procedures.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Reportable incidents, with the exception of expected deaths, were noted to not have been reported. Please review incident reporting policy and ensure it aligns with Schedule D of the Residential Care Regulation.
      • 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): It was noted the complaints procedure did not include contact information for Licensing, or the Patient Care Quality Office, and was not provided upon admission.
      • R2.1J - Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(a)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Performance Evaluations continue to be incomplete.
      • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): During inspection it was noted common areas, and multiple bedrooms in poor state of repair. Chipped paint, large scratches in walls, missing trim and tape used to repair walls were all noted during inspection. It was also noted that fluorescent light fixture covers in common areas were in need of cleaning. Please inform licensing of the plan and systems put in place to ensure damaged surfaces are repaired, and ongoing maintenance is completed to ensure dignity of person in care.
      • 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): Wound care plans were noted to be unclear in directions, and to be inconsistent in providing start dates for treatment. Also noted to be inconsistently documented.
      • R10.3L - Review and modify a care plan with the person in care's participation to the extent reasonably practical; 81( 4 )(c)
  10. Monitoring

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system to ensure all reportable incidents are reported to Licensing is not working. LO noted that zero reports for unexpected illness have been recorded for the year of 2016. Please inform licensing of the process you will implement to ensure ALL incidents, as defined in schedule D of the RCR, are reported to licensing.
      • 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system to ensure performance reviews are conducted on a regular basis does not seem to be working. This is an outstanding contravention. There is a new manager in place since the last inspection. Please inform licensing of the system you will implement to ensure compliance with section 40(1) of the RCR.
      • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): There is not a medication safety advisory committee (MSAC) currently in place. There has not been a MSAC meeting in the last year. There is no evidence of a medication room inspection conducted in the past year. Please inform licensing of the process or system you will implement to ensure compliance with section 68 of the RCR.
      • R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)
      • R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(b)
  11. Monitoring

    4 infractions

    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Most recent routine inspection report not displayed in a prominent place.
      • 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)
    • 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): Most recent routine inspection report not displayed in a prominent place.
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Staffing records were audited. Some employee performance reviews were not complete. Licensee is currently working towards completion.
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40(1)(a)(b)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): 1) Water temperature accessible to persons in care exceeds 49 degrees Celsius 2) Ceiling panels in some areas of the facility appear broken and or cracked. In one area of the facility the ceiling panel appears to have some water damage. 3) Some fluorescent lights appear to have flies and other debris present.
      • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • 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)