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McKim Cottage

916 11 St Nelson BC V1L 7A6 · Residential Care - Licensing

7 inspections

  1. Routine Inspection

    4 infractions

    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): In a random audit of client records, licensing noted the current system in place to document person in care's immunization status is not effective. The licensee utilizes a Referral Form to capture this information but the forms reviewed were not filled out.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): The entrance to the facility has not changed since the previous inspection where it was noted to be a challenge for persons in care with mobility aids. This was identified during the previous inspection conducted November 2, 2023. The licensee did have evidence of a work order being submitted, however the work was not completed. This is now an OUTSTANDING infraction.
      • R7.2A - Ensure that persons in care who require mobility aids can access all areas intended for use by persons in care; 14 ( 1 )
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): In discussion with the licensee it was noted that performance reviews have not been occurring regularly.
      • R3.1N - 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): Although there is a supervising pharmacist for the facility, there has not been a medication room inspection since 2023.
      • R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(b)
  2. Routine Inspection

    2 infractions

    • R7.2 - Is the environment maintained to prevent falls?
      • Observation(s): During the inspection, it was noted that a person in care with a mobility aid had difficulty entering the facility, and accessing the bath tub. Licensing noted that the bath tub did not have slip resistant material, nor is there a current system in place for individuals to use non-slip mats.
      • R7.2A - Ensure that persons in care who require mobility aids can access all areas intended for use by persons in care; 14 ( 1 )
      • R7.2P - Ensure bathrooms have slip resistant material on the bottom of each bathtub and shower; 30(b)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): In review of admission records, Licensing noted that there is not currently a process to get written consent from persons in care to call a doctor or ambulance in case of accident or illness.
      • R4.1I - Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
  3. Routine Inspection

    2 infractions

    • R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
      • Observation(s): Licensing officer noted that numerous care plans for persons in care outline interventions which are to be carried out by "McKim Nurse", however, it is noted that there is not a nurse on duty over the weekends or statutory holidays. Currently, if a person in care requires assessment or new medication over a weekend, the person in care is transferred to ER as there is not a nurse on duty. In addition, if there are new medication orders over the weekend, the medication is not started until the nurse returns to work.
      • R3.2A - There must be sufficient numbers of trained and experienced employees on duty at all times. Staffing patterns must meet the needs of persons in care and assist persons in care with activities of daily living, including eating, mobility, dressing, grooming and hygiene in a manner consistent with the health, safety and dignity of persons in care; 42( 1 )(a)(b) (Show More)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): The system to ensure that food is safely stored appeared ineffective. Licensing officer noted a thermometer in the fridge which, at the time of the inspection, was reading within an appropriate range. However, Licensing is unable to confirm that the temperature is continually maintained within a safe range for food storage.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
  4. 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): A sheet describing the rights of medication administration posted in the medication room was outdated as it did not coincide with the medication administration policy in the MAR. This was corrected during the inspection.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
  5. Monitoring

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): In discussion of the incident reporting process at the facility, it was discovered that some incidents where residents are transferred to acute for higher level of care, fit in the definition of unexpected illness under schedule D of the RCR. Not all incidents which are reportable to licensing have been reported.
      • 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 facility's procedure for staff training of of emergency plans indicates that fire drills are to occur monthly. This is not currently happening at the facility.
      • R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The kitchen linoleum flooring is torn under and around the base of the fridges. This is an OUTSTANDING contravention as it was indicated on the inspection report from August of 2016. The main carpet throughout the facility is stained and showing signs of wear and tear. This is an OUTSTANDING contravention as it was identified on the inspection report from August of 2016. Please provide a plan to licensing as to how and when these items will be addressed before the above date.
      • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  6. Monitoring

    2 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): Some policies and procedures noted on the previous inspection report (dated January 14, 2015) have not yet been updated (including the emergency plan specific to the facility). The Team Leader stated that this is a project she has scheduled to work on in September (she is also updating the orientation manual at the same time).
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The kitchen linoleum flooring is torn under and around the base of the fridges. The main carpet throughout the facility is stained and showing signs of wear and tear. The Team Leader indicated the Licensee has already sought out quotes to have this flooring repaired. At the time of visit, it was noted the last fire/sprinkler inspection was completed in November 2014; and "annual interior inspection" was completed in 2013.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 ( 3 )
  7. Monitoring

    4 infractions

    • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): Upon chart review, not all residents had an up to date immunization status. This was corrected during the inspection.
      • 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
    • 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): The evacuation plan is in DRAFT form posted by the front door. The is also another evacuation plan which has a different evacuation site listed in the Emergency Response Manual. CORRECTION DATE: JANUARY 30, 2015. The facility is currently missing some of the required emergency/fire equipment, as indicated by a recent fire inspection, (doors, signage). The assessment process is underway to correct this. CORRECTION DATE: please provide a plan to licensing by FEBRUARY 28, 2015. Of the policies reviewed, all were outdated and overdue for revision/review. CORRECTION DATE: FEBRUARY 28, 2015. The polices required by licensing per section 85 (2): -orientation of new managers/employees, including orientation to the Regulations and the Act. -continuing education of employees/managers -complaint process and dispute resolution -access to persons in care who are not employees of the facility -release of vulnerable adults from the facility -monitoring nutrition of persons in care -monitoring medication of persons in care -the use of restraints in an emergency -responding to reportable incidents (include a list of reportable incidents "schedule D") -steps to be taken if a person in care leaves, or may have left, the community care facility without notification of an employee -the appropriate manner and schedule of record keeping
      • Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51(1)(a)
      • Review and, if necessary, revise policies and procedures at least once a year; 85(1)(b)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): One fridge was noted to be missing a thermometer. CORRECTION DATE: JANUARY 30, 2015.
      • Ensure that food is safely prepared, stored, served and handled; 63 (11)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): One of the bedrooms has a notable draft from the window. CORRECTION DATE: JANUARY 30, 2015. Numerous gardening supplies and shovels were noted in the basement which can be accessed by residents while doing laundry. CORRECTION DATE: JANUARY 30, 2015.
      • Room temperatures must be safe and comfortable; 16 (11)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35(1)(c)