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Birch Lodge

7446 Hwy 6 Coldstream BC V1B 3H4 · Residential Care - Licensing

Official record from Interior Health →

Inspection summary

Birch Lodge has been inspected 8 times by Interior Health Authority since November 20, 2015. The most recent inspection, on July 8, 2026, recorded 1 infraction.

1 of 8 inspections on record found no infractions at all. In the past 12 months there were 2 inspections with 1 infraction recorded. All recorded findings relate to upkeep, equipment or paperwork rather than direct health risks.

Recent inspections have recorded fewer infractions than earlier ones, so the record is improving.

What these findings mean

Health authorities word their findings differently, so we group them by what they mean for the people in care. Higher-risk findings are the ones that could directly make someone sick, and they matter more here because young children, older adults and people who are unwell are more vulnerable to infection.

  • Permits, records and postingLower risk

    Operating permits, required signage, written procedures and logs. These findings are administrative: the documentation was missing or out of date at the time of inspection.

    Recorded 13 times across 7 separate inspections, most recently on July 8, 2026. For example: 3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?

  • Equipment and utensilsLower risk

    Equipment has to be made of cleanable materials, kept in good repair and stored properly. These findings are mostly about upkeep, like a cracked surface or worn part. They are generally lower risk but show how well the place is maintained.

    Recorded once on February 4, 2020. For example: 1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?

  • Other findingsLower risk

    Findings that do not fit the categories above, such as follow-ups that confirm an earlier violation was corrected, or requirements specific to this type of facility.

    Recorded 4 times across 3 separate inspections, most recently on February 4, 2020. For example: RB1.5 - Are persons in care informed on how to express concerns or make complaints to the medical health officer or to the Patient Care Quality Office prior to admission?

About this data

These results come from Interior Health Authority, which inspects food premises and other public facilities in this area. We republish the authority's public disclosure data and refresh it regularly; the official record is the final word.

8 inspections

  1. Routine Inspection Follow-up

    1 infraction

    • 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 review of the incident report, it was determined that a person in care did not have a care plan as required. A lack of care plan poses a risk to the health and safety of persons in care as without one, staff are unable to know all the physical, social and emotional needs 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)
  2. Routine Inspection

    0 infractions

  3. 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): Emergency plan was not displayed in the facility.
      • R2.1I - Display a copy of the emergency plan in a prominent place; 51 ( 4 )
  4. 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): Licensing reviewed the system in place to review and/or revise policies annually. There is no system in place to document when this occurs. The licensee advised Licensing this process would be added to a checklist to ensure documentation is complete.
      • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing reviewed person in care records. The records for the person in care, most recently admitted were incomplete. -Height and weight on admission was not documented. -A written consent to call a medical practitioner or ambulance in case of an emergency was not completed. This is a re-occurring contravention from February 2020. -A full care plan had not been completed within 30 days of admission.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • 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)
      • R4.1Q - Ensure a care plan is developed within 30 days for persons in care admitted for more than 30 days; 81.1; Director of Licensing Standards of Practice: Advance Directives and Care Plans
  5. Routine Inspection

    5 infractions

    • RB1.5 - Are persons in care informed on how to express concerns or make complaints to the medical health officer or to the Patient Care Quality Office prior to admission?
      • Observation(s): The facility had an excellent internal system in place, tailored to the person in care's cognitive ability to make complaints, internally. This internal complaint system however, did not inform the persons in care how to make a complaint to the medical health officer, or Patient Care Quality Office.
    • RB1.6 - Are persons in care informed of all charges, fees and other amounts that must be paid for accommodation and other services prior to admission?
      • Observation(s): Facility does not have a document to inform the person or care, nor their representative, of all fees and charges for accommodations and other services.
      • RB1.6A- Inform persons in care of all charges, fees and other amounts that must be paid for accommodation and other services prior to admission.
    • 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): Facility did not have an admission policy in place to inform the person in care, or the person's representative, of all charges/fees/other payments for accommodation or other service. Although facility has not admitted a new Person In Care in a few years, the facility is required to inform the person in care, or the person's representative, of all fees.
      • R2.1A - Advise of all charges/fees/other payments for accommodation/other services offered prior to admission; 48( 1 )(a)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): The Person In Care files that were reviewed by Licensing, did not contain consent to call a medical or nurse practitioner or ambulance.
      • 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)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Facility did not provide persons in care with bedroom furnishings that included a safe, secure place to store valuable property.
      • R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 1 ) (a)
  6. 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 immunization records are complete is ineffective. There was no immunization documentation on record for a staff member.
      • R6.1A - Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 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): The system for ensuring written policies and procedures for orientation of new managers and employees to the regulations and the Act is ineffective. The orientation sheet did not include orientation to the Regulation or the Act. This item remains outstanding from the previous inspection report.
      • 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)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): The system for ensuring criminal record checks are obtained is ineffective. There was no criminal record check on file for one of the new employees hired. Although the facility has applied to the Ministry, this was not completed prior to the staff member being hired.
      • R3.1B - Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
  7. Monitoring

    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): There was no indication in the orientation policy or orientation check off sheet of any reference to the Regulations or 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)
    • 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 compliance with reviewing care plans at least once a year is ineffective. A sampling of care plans were reviewed and one care plan had not been reviewed for over one year.
      • 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)
  8. Monitoring

    4 infractions

    • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): A sampling of staff records were reviewed and immunization screening was incomplete on one of the records.
      • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): A sampling of staff records were reviewed. An RCMP criminal record check was completed and on file which does not meet the standard of the Regulation. BC Ministry criminal record checks are required.
      • Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
    • 4.4 Are records kept on each employee with the necessary requirements?
      • Observation(s): A sampling of staff records were reviewed and although there is a covering sheet on each employee indicating reference checks were complete, reference checks were not on file. This remains outstanding from the past inspection report.
      • Keep employee character references; 86(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): Weights have not been recorded on a person in care for an extended period of time for specific reasons related to the person in care. The care plan did not indicate reasons for this and steps to take for monitoring any weight change. The care plan was updated during the inspection.
      • Record in the nutrition plan the reason why a person in care has refused or is unable to be weighed and that immediate advice is sought of a health care provider when it appears that a person in care may have experienced a significant change in weight; 83( 5 )(a) (b)

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