Middleton House
10306 Middleton Dr Vernon BC V1T 2K6 · Residential Care - Licensing
13 inspections
- Routine Inspection
0 infractions
- 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): Staff did not follow facility policies regarding weight records. While weights were charted, significant fluctuations were not accounted for or reviewed.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Lower common area has damage to walls; damage to walls throughout facility including a small hole in staircase wall. Damage is mainly cosmetic however is unsightly.
- 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): A weight record was inconsistently charted with variations in weight. While the variations may have been accounted for due to issues with a scale, there was no further investigation done at the time or documentation completed by staff.
- R10.3R - Seek immediate advice from a health care provider if a person in care has experienced unintentional and significant change in weight; 83( 4 )(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?
- Substantiated complaint
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): Staff administered sennosides twice in the morning of January 4, 2024, contrary to directions on the medication administration record. Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee Residential Care Regulation 68 (4)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): A medical professional (either MRP or HSCL nurse) was not consulted on day 5 of the bowel protocol for direction regarding the PIC who was in discomfort and agitated.
- R10.2G - Assist persons in care to obtain health services as required and ensure that a medical or nurse practitioner can be contacted in an emergency;54( 2 )(a),54( 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 PIC's care plan was not updated and didn't reflect the behavioural interventions that the licensee employed.
- R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
- 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?
- Substantiated complaint
2 infractions
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Concern alleged fire drills are not completed and are signed off as if they were conducted. A review of the fire drill documentation provided by the facility indicates that there were numerous drills conducted in February and May and only one in December. This contravenes the facility policy of having fire drills every three months. Concern alleged that there are a significant amount of medication errors. The system to ensure that staff are complying with the policies and procedures for documenting medication administration is ineffective. A review of the medication administration records identified PRN’s from a blister pack that were unaccounted for and PRN medication that was identified as given on the blister pack but not documented on the Medication Administration Record.
- R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
- R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Concern alleged that menu planning is not taking into account the nutritional plan of person in care. The six week menu rotation for the fall/winter months from 2021 and 2023 was reviewed and found to be identical. There was no evidence to indicate that the meal planning process had taken into account the nutrition plan of each person in care.
- R5.1E - Provide a variety of foods in consideration of each person in care's nutrition plan and needs; 62( 2 )(c)(i)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Substantiated complaint
2 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Concern alleged that the painting of the upstairs walls of the facility was not reported as required. Licensing reviewed facility documentation, confirming that the event was not reported as required.
- 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)
- 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): Concern alleged that a person in care did not receive exercises as per the care plan. Licensing reviewed the care plan which referenced a Health Services for Community Living (HSCL) physiotherapist identifying an exercise plan being created for the person in care. Facility manager confirmed the exercises had not being implemented.
- 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
- R4.5 - Are incidents and notifications reported and records retained as required?
- Substantiated complaint
2 infractions
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Concern alleged that the tube feeding schedule was changed by a facility nurse without direction from the Dietitian. Facility investigated and facility manager confirmed that the schedule had been changed by the facility without direction.
- R5.1V - Provide tube feedings ordered by a person in care's medical or nurse practitioner; 67( 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): Concern alleged that the oral care plan for post-op orders was not revised. Licensing reviewed documentation with no evidence to suggest that the oral care plan was revised. Concern alleged that a swallowing assessment resulting in a diet change, was not implemented by staff. Licensing reviewed documentation including the facility communication book as well as interviewing HSCL OT who observed wrong texture of diet provided to person in care.
- 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)
- 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
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Routine Inspection
3 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Medication administration records were reviewed during this inspection, the effectiveness of a PRN medication was observed to not have been charted.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): During inspection of care plans, it was observed that a restraint agreement had not been renewed by the stated renewal date.
- 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): During the physical inspection of the facility, It was observed that there were several holes in the ceiling of a Person in care’s bedroom.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
2 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Licensing became aware of a manager change while scheduling this inspection. The Licensee thought a notification had been submitted to Licensing. Notification details have been received prior to completion of this report. No further action is required.
- 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): On physical inspection of the facility, Licensing noted walls throughout the building requiring repair and painting. Licensing observed holes and deep scrapes as well as some damaged that has been filled but not painted. Floor boards have started to pull apart but are not yet to the point of creating a falls hazard.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Routine Inspection
0 infractions
- Monitoring
1 infraction
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): The system for ensuring compliance with tuberculosis control program for persons in care is ineffective. There was no completed TB screen on record for one of the persons in care.
- R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Monitoring
5 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): It was noted that the monitoring process for policies and procedures was ineffective. The complaints policy indicated there is a complaints form included in the policy. There was no complaints form included in the policy. The interim manager printed out the form and added the form to the policy. This item was corrected during the inspection.
- Ensure there are written policies and procedures for how persons in care, their parents or representatives and contact persons may express concerns, make complaints and resolve disputes under section 60; 85( 2 )(d)
- 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): It was noted that the monitoring process for food services was ineffective. The interim manager stated that the facility just changed their menu to the summer menu plan. Several days on the snack menu plan only had one food group item as well as tea/coffee. Tea/coffee are not food groups described in the Canada Food Guide. This infraction type was noted on the past inspection report but under a different circumstance (snack menu indicated "individual choice" which did not include what was being provided in the facility) The menu plan now contains specific snacks outlined on the menu but does not meet the standard of the Regulation.
- 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): It was noted that the monitoring process for safe food storage was ineffective. The temperature of the fridge on the main level read minus 5 to minus 8 during the inspection. Several temperatures on the temperature log were noted out of the safe food storage range without any follow up of the facility. It was questioned whether the thermometer was working properly, as there was no food noted to be frozen in the fridge area.
- Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): It was noted that the monitoring process for maintaining the safety in all rooms and common areas was ineffective. On the outside deck there was a large temperature monitoring fork attached to the barbeque handle. The fork had two large sharp tongs. The interim manager removed the fork from the barbeque handle and placed the fork in the barbeque storage area behind the propane tank. This item was corrected during the inspection.
- Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- 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): It was noted that the monitoring process for significant weight loss was ineffective. The care plan for one person in care indicated that if the person in care lost 8 pounds or more in one month, the dietician is to be contacted. The monthly weight taken indicated there was over 8 pounds lost in one month. It was questioned as to whether the weigh scale was working properly. A discussion also took place with the interim manager as to what the follow up steps would be when the staff notice a significant weight change.
- Seek immediate advice from a health care provider if a person in care has experienced unintentional and significant change in weight; 83( 4 )(b)
- 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?
- Monitoring
5 infractions
- 2.2 Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): Written consent from a medical or nurse practitioner was not on file for a restraint being used on a person in care. This item remains outstanding from the previous inspection.
- 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)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Several missed signatures were noted on the Medication Administration Record for regularly scheduled medications. This item remains outstanding from the previous inspection.
- Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): "Individual choice" was noted on the snack menu plan without mention as to which food group or choice of snack the choice pertained to. This item remains outstanding from the previous inspection.
- 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): The fridge temperatures in the lower level are not being completed on a regular basis. Last temperatures logged were Aug. 3, 2015. This remains outstanding from the previous inspection.
- Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Light fixture missing from a light by the medication cart on the main level. Baseboard broken and coming off the wall in main living room. Patio swing cushions are damaged and torn. Patio deck is stained and in need of a cleaning. Cupboard underneath sink in main kitchen and closet on main floor by large bathroom found to be unlocked and cleaning supplies accessible to persons in care. This item needs to be followed up Aug. 26, 2015.
- 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)
- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- 2.2 Are written policies and procedures in place to guide staff in fall prevention?
- Monitoring
13 infractions
- 2.2 Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): Written consent from the medical or nurse practitioner was not on file for a restraint being used on a person in care.
- Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73(2); 75(2)(a)(i)(ii)(b)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Several missed signatures were noted on the Medication Administration Record.
- Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78(2)(b)
- 4.3 Is documentation concerning restraints adequate?
- Observation(s): A restraint was scheduled to be reviewed in December of 2014. There was no documentation to indicate that the restraint had been reviewed with the result of the reassessment.
- Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
- 8.1 Is there an ongoing planned program of physical, social and recreational activities?
- Observation(s): Program calendar in the basement level did not include ongoing planned program of physical, social and recreational activities.
- Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55(1)(a)(i)
- 8.2 Does the program of activities support individualized care plan requirements?
- Observation(s): Program calendar in the basement level did not include any programs for numerous days during the one month period.
- 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)
- 13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
- Observation(s): As per inspection report - inadequate recreation calendar.
- 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): Reportable incident policy did not include aggression between persons in care. (Schedule D)
- 4.1 Are person in care records current, complete and kept confidential?
- Observation(s): Several monthly weights were missing from the records of a person in care.
- Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83(4)(a)(c)
- 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Menu did not contain at least two food groups for each snack being provided by the facility.
- Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62(2)( c)(i)
- 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): A plate of food was not labelled with a date and was stored on top of a tray of chicken. Temperature logs were missing for the upstairs kitchen fridge and temperature logs were not marked indicating the temperature of the fridge located in the basement kitchen.
- Ensure that food is safely prepared, stored, served and handled; 63 (13)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Damage to walls noted through out the facility. Railing next to the gate entrance on the deck noted to be loose. A garbage can as well as a walker and other equipment was stored by one of the exits on the lower level obstructing a small area to the door swing as well as risking a clear exit in an emergency. An email was received from the quality assurance representative the same day of the inspection indicating that exit had been cleared and this was resolved. A fire inspection took place within the last year but there was no evidence on site that the sprinkler had been tested. The fire extinguishers as well as emergency lighting had tags on them that they had been checked in Oct. 2014. Several cans of paint were being stored in a downstairs closet accessible to persons in care. An email was received from the quality assurance representative that a lock was placed on the closet door and this was resolved.
- Maintain all rooms and common areas in a good state of repair; 22(1)(b)
- Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 (14)
- Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signaling devices; 22 (15)
- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35(1)(c)
- 9.1 Are medications stored, handled, and administered appropriately?
- Observation(s): Last Medication Safety and Advisory Meeting minutes and pharmacy visit noted to be Oct. 2013. Previous minutes and inspections were being completed on a yearly basis.
- Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68(2)(a)(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): A sampling of person in care records were reviewed an it was noted that in all samples, care plans including nutritional and oral care plan has not been reviewed for over 1 year.
- 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)
- 2.2 Are written policies and procedures in place to guide staff in fall prevention?