Ord Road Group Home
3510 Ord Road Kamloops BC V2B 8B6 · Residential Care - Licensing
11 inspections
- Routine Inspection
5 infractions
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): During a review of furniture and equipment for use by PICs, it was observed in the main floor bathroom that the transfer pole was not replaced as outlined within the corrective action plan dated March 4, 2025 (accepted by Licensing). Rust was observed on the transfer pole and it was reported that the rust had been painted over. **This is a repeated contravention. When furniture and equipment for use by PICs are not maintained in a safe and clean condition, it increases risk to PICs health, safety, and dignity. Submit by May 15, 2026, evidence that furniture and equipment for use by PICs are maintained in a safe and clean condition.
- R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): During a review of PRN (as needed) medication documentation, it was observed that one PRN medication that was administered was not signed for on the Medication Administration Record (MAR). Further review of the Staff Medication Check Sheet revealed that, on the same date for the same medication, two staff signed that medication documentation was complete. **This is a repeated contravention. When PRN medications are not documented completely, there is risk of medication error. Submit by May 15, 2026, evidence that for all persons in care (PICs) who require PRN medications, PRN documentation is completed.
- R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): During a review of monthly weight records for PICs it was observed that, for one PIC, the weight was not recorded for one month and there was no documentation of why the PIC was not weighed. The absence of recorded monthly weights increases risk to PIC's overall health and nutritional status. Submit by May 15, 2026, evidence that all PICs are weighed and that weights are recorded at least once each month.
- 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): During a review of menu substitution records, it was documented that for four days in February 2026, the items substituted stated “quite a few”, “missing”, and “ran out”. It also did not indicate the specific foods substituted. When menu substitutions are not recorded as required, documentation does not provide information that PICs are being offered the type and amount of food groups as described in Canada's Food Guide, which increases risk to persons in care's overall health and nutritional status. Submit by May 15, 2026, evidence that menu substitution records contain the required substitution information.
- R4.6C - Retain food services records of menus and menu substitutions; 87(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): During a review of rooms and common areas, it was observed in the main floor bathroom that the possible water damage to the drywall and baseboard trim, to the right of the bathtub, appears to not have been repaired or replaced as outlined within the corrective action plan dated March 4, 2025 (accepted by Licensing). **This is a repeated contravention. When rooms and common areas are not maintained in a safe and clean condition, it increases risk to PICs health, safety, and dignity. Submit by May 15, 2026, evidence that rooms and common areas are maintained in a safe and clean condition.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R7.2 - Is the environment maintained to prevent falls?
- Routine Inspection Follow-up
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 policies are implemented by employees is ineffective. On a review of three staff files, the driver's abstract for one staff member was not completed at the frequency directed by facility policy.
- 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
3 infractions
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): The system to ensure that all furniture and equipment for use by persons in care are maintained in a safe and clean condition, is ineffective. Rust was observed on the transfer pole, and rust and chipping were observed to the sink and bathtub, in the main floor bathroom.
- R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(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 that all employees comply with the policies and procedures of the medication safety and advisory committee is ineffective, as demonstrated by the following: - A review of PRN (as needed) medication administration records identified several instances where PRN medication effectiveness was not documented. - A review of PRN medication administration records identified several instances where PRN medication names and amounts administered were not documented.
- R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The system to ensure that all rooms and common areas are maintained in a good state of repair is ineffective, as demonstrated by the following: - Worn, peeling paint, and separated inset panel to overhead garage door. - Rust to the front gate. - General deterioration of the exterior physical facility. The system to ensure that all rooms and common areas are maintained in a safe and clean condition is ineffective, as demonstrated by the following: - Possible water damage observed to the drywall and baseboard trim, in the main floor bathroom, to the right of the bathtub. - It was observed that several areas of the concrete walkways, surrounding the facility, have eroded or heaved creating uneven surfaces and pose tripping hazards.
- 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)
- R7.2 - Is the environment maintained to prevent falls?
- Routine Inspection
7 infractions
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): The system to ensure that persons in care comply with the Province's tuberculosis control program is ineffective. There was no evidence that persons in care are screened upon admission.
- R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): It was observed in the main floor bathroom that there was no slip resistant material on the bottom of the bathtub.
- R7.2P - Ensure bathrooms have slip resistant material on the bottom of each bathtub and shower; 30(b)
- 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): See R2.1C.
- 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 noted during inspection that prior to admission, one person in care's representative was not informed of how to express concerns or make complaints to licensing. It was observed that a copy of the emergency plan was not displayed in a prominent place. The emergency plans had been removed due to interior painting and had not been replaced. *Corrected during inspection. The system to ensure that policies are implemented by employees is ineffective, as described by the following: It was noted during inspection that the facility is not up to date with monthly fire drills, as required by facility policy, and as evidenced by documentation showing the months of April, May, August and October of 2023 being absent. It was noted that emergency "grab and go" bags for two persons in care, as required by facility policy, are incomplete.
- 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)
- R2.1I - Display a copy of the emergency plan in a prominent place; 51 ( 4 )
- 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): It was observed that the menu did not provide at least 3 food groups, for each meal per day, as described in Canada's Food Guide. It was observed that the menu did not provide at least 2 food groups, for each snack per day, as described in Canada's Food Guide.
- 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)
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): The system to ensure that best before and expiry dates for food are monitored is ineffective. It was observed that food was dispensed into secondary containers without expiry or best before dating.
- 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): The system to ensure that all common areas are maintained in a safe condition is ineffective. It was observed that there was a loose stair tread nosing, missing nails, near the uppermost bedroom.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Routine Inspection
2 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Incident reporting for the past year was reviewed for this inspection, some incident reports were received 2-3 days after the incident. The facility is in the process of updating procedures to ensure IR's are received immediately. Please inform Licensing of the updated procedures.
- 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The furnace room door was unlocked at the time of this inspection, several items are stored in this area that could be potentially harmful to persons in care if accessed. Door locked at the time of the 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
3 infractions
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Facility procedure of signing out PRN medication when leaving the facility not completed the date of this inspection. Please ensure employees comply with facility policies and procedures.
- R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): Height of person in care not recorded. Please ensure height and weight are documented on admission.
- R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Bathroom fan and kitchen light observed as requiring cleaning. Please ensure facility fixtures are maintained to be in a clean condition.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Routine Inspection
1 infraction
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The stair rail off of the back deck was noted as loose at the time of this inspection, please examine to determine if any repairs are needed.
- R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Monitoring
2 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): Some PRN charting observed during this inspection did not include the result of the medication administered, facility medication procedure is to document the result; inform Licensing on what systems and audits will be implemented to ensure PRN charting is completed.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The facility outdoor sitting area currently does not have a sheltered area from the sun, inform Licensing on how this will be rectified.
- R7.1AN - Provide outside activity areas that have comfortable seating including a reasonable amount of shelter from sun and inclement weather; 36 ( 1 ) (c)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
2 infractions
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): Self monitoring procedures are in place at the facility, picnic table in the facility outdoor recreation area is in poor state of repair (chipping paint), ensure physical self monitoring includes outdoor equipment. Inform Licensing regarding follow-up with the table and that self monitoring procedures have been updated.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- 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): Recreation plans are in place for PIC's, daily charting reviewed did not always include details of activities that occurred. Ensure daily charting includes details of daily activities including specifics regarding specified recreation gaols in PIC's recreation plans. Please include in your response how the identified recreation goals for each PIC are audited.
- R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Monitoring
2 infractions
- 7.2 Is the environment maintained to prevent falls?
- Observation(s): One bedroom window on the second floor of the home has a broken safety latch, this allows the window to open all the way. Ensure all windows in the home are secured to allow the window to open only 4 inches to avoid potential falls or elopement risks.
- Windows must be secured to prevent falls from, or exiting through, the window; 15 ( 1 )
- 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): Ensure facility cleaning policies are reviewed to include specific instructions for staff regarding cleaning procedures; procedures should include types of cleaners to be used, areas specific cleaners are used and mixture procedures for cleaners.
- Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
- 7.2 Is the environment maintained to prevent falls?
- Monitoring
2 infractions
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): PRN medication documentation does not always include the reason and result of the medication administered, ensure medication procedures include the requirement for staff to chart reason and result. Reviewing med charting could also be included in facility self monitoring procedures to ensure staff compliance.
- Keep a medication administration record showing all medications administered to the person in care; 78(2)(a)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Cupboard door in main floor washroom has a broken hinge, please repair door to ensure it functions properly.
- Maintain all rooms and common areas in a good state of repair; 22(1)(b)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?