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Hawthorn House

4217 16 Ave Vernon BC V1T 6P2 · Residential Care - Licensing

6 inspections

  1. Routine Inspection

    3 infractions

    • 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 checklists are completed as required is ineffective. A review of the House binder containing Wellness and Safety Daily checks, Daily equipment record checks, the Daily shift duty checklist and Evening shift duty checklists, all were noted to have sporadically missed signatures. Incomplete checklists may indicate that processes and checks were not completed, potentially compromising the health, safety and dignity of persons in care. Submit by January 8, 2026, the plan that will be implemented to ensure ongoing compliance with Section 85(1)(d) of the Residential Care Regulation. The plan must include your process for ongoing monitoring of the updated system.
      • 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 that persons in care are weighed monthly is ineffective. A review of Sharevision identified several missing months of unrecorded weights. The absence of documented monthly weights increases the risk of inaccurate nutritional monitoring of persons in care. Submit by January 8, 2026, the plan that will be implemented to ensure ongoing compliance with Section 83(4)(a) of the Residential Care Regulation. The plan must include your process for ongoing monitoring of the updated system. The system to ensure that persons in care are weighed monthly is ineffective. A review of Sharevision identified several missing months of unrecorded weights. The absence of documented monthly weights increases the risk of inaccurate nutritional monitoring of persons in care. Submit by January 8, 2026, the plan that will be implemented to ensure ongoing compliance with Section 83(4)(a) of the Residential Care Regulation. The plan must include your process for ongoing monitoring of the updated system.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R4.6 - Are facility records current and complete?
      • Observation(s): The system to record food substitutions is ineffective. A review of the food substitution list identified no substitutes for the year. Facility acknowledged that they had not documented food substitutions as required. Failure to maintain a food substitution list compromises the ability to monitor that substitutions are made from the same food group and have a similar nutritional value as the planned menu. Submit by January 8, 2026, the plan that will be implemented to ensure ongoing compliance with Section 87(b) of the Residential Care Regulation. The plan must include your process for ongoing monitoring of the updated system.
      • R4.6C - Retain food services records of menus and menu substitutions; 87(b)
  2. 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 self-monitor the facility is ineffective. A review of a facility binder containing checklists for Daily equipment check record, Daily shift duty checklist and Evening shift duty checklists, all were noted to have missed recordings. The Wellness and safety checklist was noted to have missed checks and that the frequency of checks was either missing or inconsistent from one day to another.
      • 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): The system to ensure that persons in care have consented to the facility calling a medical or nurse practitioner or ambulance in case of an accident or illness is ineffective. There were no consents in writing from a person in care or a representative of the person.
      • R4.1L - 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The system for maintaining the physical environment is ineffective as noted by wall damage and paint peeling off walls throughout the facility.
      • 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): The system to ensure that monitoring the health and safety of each person in care regularly to determine if their needs continue to be met is ineffective. A review of the Staff acknowledgements that they have read and understood individual person in care’s information identified missing staff signatures for seizure protocols, swallowing mealtime guide and individual goals & program. In addition, it was also observed that Vulnerability Assessment Questionnaires identifying Risk / Vulnerability areas were incomplete.
      • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
  3. Routine Inspection

    2 infractions

    • 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 observed that a binder continuing an assortment of checklists to be completed and signed by staff was not consistently signed off. An example of which was a review of the Day Shift Duty Checklist.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): In reviewing the weekly menu it was observed that it did not provide for each day of the week. For example, Lunches were listed for the entire week with seven options to choose from.
      • 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)
  4. Routine Inspection

    3 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): During review of Medication administration Records it was noted that PRN effectiveness was not consistently being recorded. This was also noted on the most recent MSAC in June 2022.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): In 2022 there were two manager changes at the facility that licensing was not informed of. Licensing was notified in May 2022 that a new manager had been in place for over a year and in November 2022 licensing was notified that there had been a new manager effective September 2022.
      • R1.1E - Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
    • 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 that a bottle of carpet cleaner was left in a unlocked bathroom cabinet which is accessible by Persons in Care. Cleaner was removed at time of inspection. Please inform Licensing to what the procedures are to ensure cleaning supplies are kept inaccessible to Persons in Care.
      • 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)
  5. Routine Inspection

    2 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): August 8, 2019 -It was noted that the Licensee's system for monitoring to ensure compliance with Compliance Plans submitted to Licensing is ineffective. A Plan was submitted to Licensing on July 6, 2017 to ensure compliance with the orientation of all managers and staff to the Residential Care Regulations, and it was noted during the August 8, 2019 inspection that evidence could not be provided to indicate that the orientation system had been completed.
      • 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): August 8, 2019 -It was noted that the Licensee's system to ensure compliance with the dispute resolution process is ineffective. How to express concerns or complaints to Licensing was not included in the complaints form. OUTSTANDING from the previous inspection: -It was noted that the Licensee's system to ensure that all managers and staff are orientated to the Residential Care Regulations at the commencement of employment is ineffective. During the inspection it was noted that the Licensee had begun to prepare a binder for staff orientation to the Regulations, however a plan was not in place to have all staff review the binder.
      • R2.1C - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to licensing; 48( 1 )(c)(i)
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
  6. Monitoring

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): June 6, 2017 -It was noted that the facility's system for ensuring that all reportable incidents are reported to Licensing is ineffective as the facility's policy for reporting did not include "choking".
      • 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)
    • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
      • Observation(s): June 6, 2017 -It was noted that the facility's system for ensuring that TB screening is in the persons in care's records is ineffective, as TB screening could not be located in the records at the time of inspection. -The Manager reported that the facility RN has a record of the persons in care's immunization status, and that moving forward the Manager would ensure that this information is available in the persons in care's charts.
      • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
    • 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): June 6, 2017 -The employee orientation process was reviewed and it was noted that a system was not in place to ensure that employees are orientated to the regulations and the Act.
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)