Orchard House
901 Erickson St Creston BC V0B 1G3 · Residential Care - Licensing
11 inspections
- Routine Inspection
2 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): R4.5G - A review of internal complaints identified that a reportable incident was not reported to Licensing as required. The incident was reviewed during the inspection, including follow up actions and responses completed, and education was provided on Schedule D definitions of reportable incidents. Failure to report a reportable incident to Licensing as required under the Residential Care Regulation may delay regulatory oversight, increasing the risk of harm to persons in care and limiting the licensee's ability to demonstrate compliance. Submit by December 17, 2025, a written plan outlining how the contravention related to ensuring that all reportable incidents are reported to Licensing, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 77(2)(c) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- R4.5G - 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): R10.3G - A review of care plans identified that a care plan for a person in care that is identified as being at risk of leaving the facility, did not include a plan to prevent the person in care from leaving. The care plan did include a detailed plan to locate the person in care if they were noted to be missing from the home. The absence of required elements within a care plan increases the likelihood of inconsistent care delivery, which may compromise the well-being, safety, and quality of care for persons in care. Submit by December 17, 2025, a written plan outlining how the contravention related to ensuring care plans for persons at risk of leaving the facility include a plan to prevent persons in care from leaving the home, has been addressed. The plan must also detail the system and process that will be implemented to support the ongoing monitoring of Section 81(3)(f)(i) of the Residential Care Regulation, thereby ensuring sustained compliance moving forward.
- R10.3G - Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
2 infractions
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): It was identified during the inspection that the system to ensure persons who may leave the facility without notifying an employee are fitted with identification that cannot be easily removed is ineffective.
- R10.2M - Ensure that persons in care who may leave the facility without notifying an employee and may not be capable of identify themselves be fitted with a bracelet or other means that cannot be easily removed, indicating the person's name, facility, and emergency contact information; 56( 3 )(a)(b) (Show More)
- 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 to ensure the care plan for persons at risk of leaving the facility includes a plan to locate the person in care is ineffective. It was identified during a review of charts that a care plan did not include the plan to locate a person in care if they were to leave without notifying employees. The care plan was noted to contain information related to preventing the person in care from leaving.
- R10.3G - Ensure the care plan for persons at risk of leaving the facility includes a plan to prevent the person in care from leaving and if the person leaves without notification, a plan to locate the person in care; 81( 3 )(f)(i)(ii)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Routine Inspection
4 infractions
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): During a review of restraint documentation it was noted that monitoring documentation of restraints was inconsistently completed. This is an ongoing infraction from the April 2023 inspection.
- 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)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Licensing acknowledges effort to increase compliance of the physical environment and the care and services provided. However, self-monitoring to ensure compliance is ineffective as noted by the ongoing, and newly identified contraventions in this report. This is an ongoing contravention from the April 2023 inspection.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): It was identified during the inspection that persons in care had access to the basement of the home following a new door handle being installed. The basement contains hazardous materials, and is not intended to be accessible to persons in care. This infraction was corrected during inspection.
- 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)
- 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 a random review of medication care plans it was identified that medication care plans did not contain dates. Licensing was unable to determine if the medication care plans had been reviewed, or modified at least annually. Staff reviewed, and dated all medication care plans during inspection. This infraction was corrected during the inspection.
- 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)
- R4.3 - Is documentation concerning restraints adequate?
- Routine Inspection
7 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): The system to ensure written agreement to the use of a restraint is obtained is ineffective. In reviewing a person in care's chart it was identified that there was no written agreement to the use of restraints.
- R2.2A - 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)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): The system to ensure the date, amount, and time at which medication is administered is ineffective. Following a review of Medication Administration Records, multiple records did not contain a signature to confirm the date, amount or time a medication was administered.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): The system in place to ensure that persons in care are monitored while using a restraint is ineffective.
- 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)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The system for self-monitoring is ineffective as noted by the number of contraventions identified in this report.
- 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): It was identified during the inspection that the system for ensuring that, the policy related to the orientation of new managers to the regulations and the Act is being implemented, is ineffective.
- R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
- R4.6 - Are facility records current and complete?
- Observation(s): There is no current system to keep, or retain a record of complaints made and concerns expressed under section 60, and the responses to them.
- R4.6F - Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): There is no current system to monitor that water accessible to persons in care does not exceed 49 degrees Celsius. During the inspection it was noted that the bathrooms were not maintained in a good state of repair. This was evidenced by missing, and possibly moldy grout in the bathroom, scratched and chipped paint on baseboards, and walls.
- R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Routine Inspection
5 infractions
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): It was noted during the inspection that there is not currently a system for ensuring restraints are monitored as instructed in care plans.
- R10.4F - Employees administering a restraint must follow any instructions in the care plan of the person in care respecting the use of restraints; 73( 2 )(b)(ii)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): It was noted during the inspection that the system for ensuring annual performance evaluations are completed for all employees appeared ineffective. Multiple employees performance evaluations were noted to be overdue.
- R3.1K - 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)
- R4.4 - Are records kept on each employee with the necessary requirements?
- Observation(s): It was noted during a random audit of employee files that the system for ensuring character references are obtained appeared ineffective.
- R4.4B - Keep employee character references; 86(b)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): It was noted during the inspection that the system for ensuring only a parent or representative, or a person authorized in writing can release or remove a person in care from the facility, was ineffective.
- R10.2Q - Only a parent or representative or a person authorized in writing by that person can release or remove a person in care from the facility; 58( 1 )(a)(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): It was noted during the inspection that the system to ensure all aspects of each care plan are reviewed, and if necessary modified if there is a substantial change appeared ineffective. This was evidenced by multiple person in care's oral and nutrition care plans not containing an updated review or modification date.
- 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)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Routine Inspection
6 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): The Licensee has a system in place to ensure that reportable incidents are submitted to Licensing immediately however; a file review indicates that the reports are missing information, notably plans to mitigate future risk and confirmation of care plan reviews. As discussed, reportable incident education will be provided to the Licensee representatives at their convenience.
- 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)
- R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
- Observation(s): The Licensee does not have a system in place to ensure that an ongoing planned program of physical, social and recreational activities are in place for each person in care. It was discussed that multiple activities were in place prior to the COVID pandemic. The Licensee’s representatives reported that they will work on a calendar of activities pertinent to the current health order requirements.
- R8.1A - 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)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): The Licensee has a system in place to ensure that seasonal menus are in place however; it was noted that the menu’s snacks do not always contain at least two food groups as described in Canada’s Food Guide.
- 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)
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): The Licensee has a system in place to monitor the temperatures of the fridges and freezer however; it was noted that the temperatures were consistently out of the appropriate range, and there was not a system in place for self monitoring. The Licensee's representatives reported that a new form is being developed, guidelines for staff to be added to form, and self monitoring will take place by coordinator.
- R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): The Licensee's system for monitoring the health and safety of each person in care regularly to determine if their needs are met appears to be ineffective. It was noted during the inspection that follow up regarding a person in care's pain management had not been completed.
- R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
- 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 inspection it was noted that care plans were not consistently updated to reflect current level of care, contained generic health information that was not specific to the person in care, and did not contain dates of review.
- 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
5 infractions
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Some staff performance reviews are incomplete. This is a recurring contravention from the previous inspection report dated 07-Jun-2018.
- R3.1K - 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)
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): There is no system in place to ensure that food is stored at a safe temperature in the main fridge.
- R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): A medicated cream was noted to be stored in a locked cupboard in a person in care's bathroom upstairs. The hinge on the cupboard door was prohibiting the lock from working making this cupboard accessible.
- R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): A person in care was administered a PRN topical administration for a change in physical health. The records for this person in care were missing information as to how this issue was monitored to ensure that this persons needs continued to be met.
- R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
- 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 PRN medication protocol for a person in care was missing evidence as to how the protocol was being followed.
- R10.3J - Each care plan must be monitored on a regular basis to ensure proper implementation; 81( 4 )(a)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Monitoring
5 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): PRN charting observed indicated reason for medication but the results were not consistently recorded. Inform Licensing of what systems/audits will be put in place to ensure that effectiveness is tracked and charting is completed.
- 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): Restraint plan missing evidence of an agreement in writing by both the representative and the medical practitioner or nurse practitioner responsible for the health of the person in care. Inform Licensing on the system or audit process that will be put in place to ensure that restraint plans include agreements in writing.
- R10.4L - Ensure a person in care is not restrained for the purpose of punishment or discipline, or for the convenience of employees; 74( 2 )(a)(b)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Performance reviews of staff have not been completed according to facility policy. Inform Licensing of the system that will be put in place to ensure that each employee is reviewed regularly.
- R3.1K - 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The system for ensuring that all rooms are in a good state of repair appears ineffective. One room was noted to have chipped paint, peeled wallpaper and nails sticking out of the wall. Inform Licensing on the system that will be put in place to address that all rooms and common areas are in good repair. The wheelchair accessible deck (which is also an exit) has a board on the base of the deck that is unstable when walked on. The handrails on the ramp leading off of the deck move when touched. Inform Licensing on the system that will be put in place to address issues in all rooms and common areas to ensure they are safe. The system for ensuring hazardous items are appropriately stored appears ineffective. The bathroom on the second floor had accessible cleaning products in one cupboard. (CDI-corrected during inspection.)
- 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)
- R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- 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 required information in nutrition care plans is ineffective. Two residents noted as a choke risk were missing information on how this issue was being addressed. Inform Licensing on the system that will be put in place to ensure that any special instructions required in a nutrition plan are included in the plan.
- R10.3N - Develop a nutrition plan for each person in care and review the plan on a regular basis (Applies to a facility with 24 or fewer persons in care); 83( 1 )(a)( 3 )(a)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
2 infractions
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Licensing observed the CDSCL area staffing spreadsheet shows a new staff who works in the facility, does not have a completed Criminal Record Check (CRC) in place. A health and safety plan was put in place to ensure this staff will not work in the home until this is completed. The health and safety plan was removed on Sept 27th upon the receipt of the documentation confirming the CRC was completed. Medication Administration Record (MAR) review found inadequate responses to PRN effectiveness according to the policy of the medication safety and advisory committee.
- Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
- Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): There have be numerous repairs to the house since the previous inspection, including painting and upgrades to septic field. Walls throughout the facility are scuffed and chipped. The flooring shows signs of wear and tear. The Manager reports they are arranging to have the flooring replaced, but awaiting a contractor. This is a ongoing contravention since the previous inspection. There is an ineffective process in place to ensure all rooms and common areas are in a good state of repair.
- Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Monitoring
3 infractions
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): The effectiveness of PRN medications are not consistently being recorded.
- Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Although numerous areas of the house have received a fresh coat of paint, there are new areas with dings and scrapes to be addressed. Specifically, the wall by the back bedroom on the main floor and the wall in the resident bedroom on the main floor leading into the en-suite. Please provide a plan to licensing by March 31, 2016, as to when the painting will be completed. The light in the upstairs bathroom does not have a cover.
- Maintain all rooms and common areas in a good state of repair; 22( 1 )(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): One resident had "Health and Safety Guidelines" posted in their room dated 2013. One resident had a plan guiding care posted in both the medication room and outside their bedroom dated 2014. Two residents had outdated health care plans; one from 2013 and another from 2014. One resident's Pivot Point care plan was outdated.
- 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)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Monitoring
4 infractions
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Although some repairs have been completed, there are still numerous areas of the facility requiring attention. The hardwood flooring in some areas is very worn. Walls throughout the facility are scuffed and chipped. The flooring up the stairs is worn and the baseboards lining the stairway are heavily damaged. Please submit a plan to licensing by JUNE 19 indicating how/when these areas of concern will be addressed. A wire was being used as a latch on a gate outside a PIC bedroom. OUTSTANDING CONTRAVENTION: all purpose cleaner in a bathroom was accessible to PICs.
- 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)
- 9.1 Are medications stored, handled, and administered appropriately?
- Observation(s): There is no evidence of a medication room inspection having been completed since 2013.
- Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68(2)(a)(b)
- 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): Although nutritional assessments were being completed, one resident's assessment completed in February 2015 indicated that they needed a referral to a dietician but the referral has yet to be made.
- 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)
- 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): Resident's do not have a medication care plan. The health care plans are overdue for review/revision.
- Care plans must include a plan to address medication, including self-medication; 81(3)(a)(i)
- 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)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?