Lamton Home
650 Middleton Way Coldstream BC V1B 2V5 · Residential Care - Licensing
9 inspections
- 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 that all policies and procedures are followed is ineffective. A review of the Duty Roster checklists identified sporadically missed signatures which were not completed as per policy. Incomplete checklists may indicate that processes and checks were not completed as required. Submit by April 24, 2026, the plan that will be implemented to come into compliance with Section 85(1)(d) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
- 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): The system to ensure employees are following policies and procedures is ineffective. During a review of the Medication Administration Record (MAR) and Medication set-up checklist, it was observed that on several occasions the cosigner had not signed as required. The cosigner not complying with the policies and procedures of the medication safety and advisory committee is a potential safety risk to persons in care. Submit by April 24, 2026, the plan that will be implemented to come into compliance with Section 68(4) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
- R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): The system to ensure that the supervising pharmacist inspects and audits the area of the facility where medications are stored is ineffective. The Supervising pharmacist last inspected the site in February 2025. The absence of regular pharmacist inspections could compromise the overall medication management system, potentially reducing the standard of care. Submit by April 24, 2026, the plan that will be implemented to come into compliance with Section 68(2)(a)(b) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
- R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(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?
- Routine Inspection
2 infractions
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): During a review of restraint agreements and care plans, it was noted that the duration of the restraint and the monitoring of the person in care during the restraint was not identified. The use of a restraint without identifying the duration and monitoring increases the risk to the person in care's physical safety and emotional dignity. Submit by May 02, 2025, the plan that will be implemented identifying the duration and the monitoring requirements to ensure ongoing compliance with Section 84(d) of the Residential Care Regulation.
- 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)
- 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 observed that the facility operated two electronic surveillance cameras to monitor persons in care. There was no posted notice indicating that surveillance is being used, thereby not meeting the legislative requirements to do so. This contravention was corrected during the inspection with signage posted as required to ensure ongoing compliance with Section 19 (3) of the Residential Care Regulation. The system for maintaining the physical environment in a good state of repair is ineffective as noted by excessive wheelchair marks, dents and damage to walls and door frames throughout the facility. Regular maintenance is important to ensure the ongoing health, safety and dignity of persons in care. Submit by May 02, 2025, the plan that will be implemented to address the noted deficiencies, in addition to a plan for ongoing maintenance for the facility to ensure ongoing compliance with Section 22(1)(b) of the Residential Care Regulation.
- R7.1G - Display a notice in a prominent place if electronic surveillance is being used to transmit or record images of persons in care or members of the public; 19 ( 3 )
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R4.3 - Is documentation concerning restraints adequate?
- 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): The system to ensure that all policies and procedures are followed is ineffective. A review of the Month Ends binder identified several checklists that were incomplete. Most notable was the Duty Rosters checklist for the various shifts containing a variety of tasks which were not checked as per policy. This was also identified for the first aid kit supplies checklist in the Health & Safety binder.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- 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?
- Routine Inspection
0 infractions
- Routine Inspection
3 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Some Medication Administration Records were missing initials noting medication had been given. There is a system in place to audit records and a review of previous months MARS appeared complete.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Licensing reviewed the facility menu plans: -Not all snacks included 2 food groups (corrected during inspection). -Not all breakfasts included 3 food groups. Facility manager advised menu plans will be reviewed and revised.
- 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Licensing observed a hole in the wall of the downstairs lounge area. Licensing observed the downstairs, including the emergency exit route, floor boards have lifted creating a tripping/falls risk. Needed repairs to maintain good condition and safety have been brought forward to BC Housing however, repairs have not been completed.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
3 infractions
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): It was noted during the inspection that a person in care did not have monitoring records while in a restraint (lap-belt) at night while in a their sleep-chair. It was noted that staff perform a minimum visual check of every 2 hours, however, there is no formal documentation to show compliance.
- 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)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): While reviewing persons in care's records, it was noted that a restraint consent had not been reassessed in over 2 years.
- R10.4N - Ensure if the use of a restraint continues either continuously or intermittently, for more than 24 hours, the need for the restraint is reassessed on the earlier of the time specified in the care plan, and the time specified by the persons who agreed, and, as part of the reassessment, consult, as reasonably practical, with the persons who agreed to the restraint use; 75( 3 )(a)(i)(ii)(b) (Show More)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): It was noted that a wall at the entrance of a person in care's bedroom was marked up / damaged. Also, a loose heat register was noted near the downstairs back door. The cords for the window blinds (downstairs) were noted to be too low to the ground which could be a hazard for persons in care. There were 2 cigarette ash bins identified on the property (one on the ground near the garage door; one on the downstairs patio table). Currently, no persons in care smoke. The Manager identified 2 staff members whom will be notified that smoking on the premises is not permitted. In the upstairs bathroom, Lysol wipes and spray were noted to be on the countertop and the closet in the bathroom was unlocked, which contained other cleaning agents / chemical products / hazardous materials. The medication mini-fridge was located on the floor in the dining room. The fridge contained medications and is not locked. The medication fridge is accessible to persons in care.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R7.1M - Ensure that no one other than a person in care smokes while on the premises; 23(a)
- 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)
- R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
- R4.3 - Is documentation concerning restraints adequate?
- Monitoring
3 infractions
- R6.1 - Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
- Observation(s): The system for ensuring evidence of compliance with the Province's tuberculosis control program is ineffective. It was noted during the inspection that a staff member did not have any results on record for TB screening. What was on record for the staff member was a form which is used for residents which is not the appropriate screening accepted by Licensing.
- R6.1A - Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): The system for ensuring person in care records are complete is ineffective. It was noted during the inspection the photograph for identification was not on record for one person in care.
- R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
- 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 the care plan includes the required elements is ineffective. It was noted during the inspection specific safety equipment being used was not noted in the care plan of a 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)
- R6.1 - Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
- Monitoring
2 infractions
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): Several missed monthly weights noted on two person in care records.
- Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Damage noted to the walls of the bathing room in the basement.
- Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- 4.1 Are person in care records current, complete and kept confidential?
- Monitoring
11 infractions
- 4.3 Is documentation concerning restraints adequate?
- Observation(s): Restraints being used at the facility were not recorded in the care plan as follows: - type of restraint was not recorded in the care plan - reason for the restraint was not recorded in the care plan - alternatives considered were not recorded in the care plan - duration of the restraint and the monitoring of the person in care was not recorded in the care plan - result of reassessment was not recorded in the care plan - employee compliance was not on record
- Record the type or nature of the restraint used in the person's care plan; 84(a)
- Record the reason for the use of restraint in the person's care plan; 84(b)
- Record alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected in the person's care plan; 84(c)
- 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)
- Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
- Keep a record of employee compliance with the requirements of Division 5 (Use of Restraints) of Part 5 in the persons care plan; 84 (f)
- 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
- Observation(s): Staffing spread sheet indicated that one staff member did not have their immunization or tuberculosis screening completed. This item remains outstanding from previous inspection report.
- Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
- 10.4 Are restraint and fall prevention plans appropriate?
- Observation(s): There are no restraint monitoring tool in place for employees to use or to document that monitoring is taking place while a restraint is being used.
- Monitor the safety and physical and emotional dignity of the person in care throughout the use of the restraint and assessed after the use of the restraint, 73( 1 )(c)
- 10 -Is there an annual opportunity for persons in care and family members to establish and participate in a council to represent their interests?
- Observation(s): As mentioned previously in the inspection report - there is no annual opportunity provided for persons in care and family members to meet as a council.
- 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): Written consents were not always obtained from the medical doctor or representative for restraints being used.
- Ensure policies are implemented by employees; 85( 1 )(d)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): The staffing spread sheet indicated one staff member has an overdue performance evaluation by 3 months . This remains outstanding from the previous inspection report.
- 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)
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): One person in care record is missing the consent to call the medical or nurse practitioner or ambulance in case of accident or illness.
- 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)
- 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): The lunch menu did not contain 3 food groups described in the Canada's Food Guide. The menu did not contain 2 food groups described in the Canada's Food Guide.
- 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)
- Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
- 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): Fridge temperature logs are monitored regularly twice a week. Twice a week monitoring does not ensure safe storage. Two staff members were not wearing masks appropriately as per Interior Health Policy during influenza season. The staff members donned the masks during the inspection. This was corrected during the inspection.
- Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- Develop general facility outbreak prevention and control policies as recommended by the medical health officer; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): A door was being stored on the outside deck. Trim with nails sticking out of the trim was stored on top of this door. All persons in care would be supervised if they were outside on the deck. The storage room in the main bathroom found to be unlocked with hazardous materials such as bleach and toilet bowl cleaner accessible. The Licensing Officer went back to this room mid inspection and found the door to be locked. This was corrected during inspection. Although the person in care residing in this area of the home would not be capable of accessing this area without the assistance of staff, the hazardous materials were found to be unlocked. Mobile persons in care would have access to this area if they were in the vicinity of this bathroom.
- Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): There is no annual opportunity provided for persons in care and their representatives to meet as a council.
- Provide at least an annual opportunity for persons in care and their parents or representatives, family members and contact persons to establish councils or similar organizations to represent the interests of persons in care; 59(a)
- 4.3 Is documentation concerning restraints adequate?