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UPDATE: Submission to Ministry of Long-Term Care Public Consultation on New License & Expansion for Southbridge Care Homes Orchard Villa

Posted: October 21, 2022

(October 21, 2022)

Submission to Ministry of Long-Term Care Public Consultation on New License & Expansion for Southbridge Care Homes Orchard Villa

To:       The Director under the Fixing Long-Term Care Act, 2021

Ministry of Long-Term Care
Capital Planning Branch
438 University Avenue, 8th Floor
Toronto, Ontario M5G 2K8

Via email:

From:   Ontario Health Coalition

Re:       PROJECT #23-034 Orchard Villa , Southbridge

Date:    October 19, 2022

Under Ontario’s long-term care legislation, “A person is only eligible to be issued a license for a long-term care home if… the past conduct relating to the operation of a long-term care home or any other matter or business of the following affords reasonable grounds to believe that the home will be operated in accordance with the law and with honesty and integrity”.

The law sets out eligibility criteria including:

  • that the home and its operation would comply with the legislation and the regulations;
  • that the past conduct relating to the operation of a long-term care home affords reasonable grounds to believe that the home will be operated in accordance with the law and with honesty and integrity;
  • it has been demonstrated that the applicant is competent to operate a long-term care home in a responsible manner;
  • the past conduct relating to the operation of a long-term care home affords reasonable grounds to believe that the home will not be operated in a manner that is prejudicial to the health, safety or welfare of its residents.

In light of Southbridge’s appalling record at Orchard Villa, it would be unreasonable and contrary to law for the government to find that Southbridge is eligible to be approved for a new license and expansion at Orchard Villa. No reasonable assessment could conclude that Southbridge is competent to operate Orchard Villa, or that its conduct affords reasonable grounds to believe that the home will be operated with honesty and integrity and not in a manner that is prejudicial to the health, safety or welfare of its residents.

Orchard Villa LTC in Pickering Ontario gained widespread notoriety for its appalling record during the COVID-19 pandemic. At least 206 of Orchard Villa’s 233 residents contracted COVID-19, along with more than 100 staff. At least 70 residents died. Reports from families of residents, the local hospital, the Canadian Forces and repeated inspections before and since the first wave of the pandemic provide hair-raising accounts of failures to provide sound infection control; dire understaffing; inadequate hydration and feeding; uncleanliness; flies and cockroaches; lack of vital supplies and egregious lack of care.

According to a CBC analysis, for-profit LTC chain Southbridge, which owns Orchard Villa, had the worst record among the for-profits during the pandemic with 9 deaths per 100 residents in homes with outbreaks. Orchard Villa had at least 30 deaths per 100 residents.

Not only was Southbridge’s record hair-raising during the first wave of the pandemic, since then, their operating record continues to be extremely poor. In the thirteen months from May 26, 2020 to June 29, 2021, there were fourteen inspections carried out at Orchard Villa.  These inspections resulted in:

  • 45 Written Notifications
  • 26 Voluntary Plans of Corrections
  • 7 Compliance Orders

Many of these are major violations related to keeping residents safe from abuse, failing to follow care plans, lack of PPE, failing to keep equipment in good repair, assessments not being completed after falls, failing to provide assessments for skin breakdowns/wounds, failing to ensure that drugs are not given to residents unless they are prescribed to them, and more

After June 29, 2021, even as the consultation on its new license and expansion has proceeded, Southbridge has continued to receive non-compliance notices at Orchard Villa resulting from inspections for critical incidents, complaints and other inspections as follows:

  • A Written Notification on August 31, 2021 related to a critical incident for a resident fall and injury.
  • 3 Written Notifications and 3 Voluntary Plans of Corrections on March 10, 2022 related to falls, poor food, failure to provide PPE to staff and ensure its use for residents with infectious disease, other breaches of infection control protocols.
  • 2 Written Notifications and 2 Voluntary Plans of Corrections on March 16, 2022 related to failure to report an allegation of abuse that resulted in an injury to a resident.
  • 2 Written Notifications and 1 Compliance Order on June 8, 2022 related to failure to report an allegation of abuse, failure to meet minimum heating temperatures in January, and another fall that resulted in the residents’ death.

Thus, in the most recent year, Orchard Villa has again been found non-compliant repeatedly resulting in escalating enforcement attempts including: another 11 Written Notifications, 5 Voluntary Plans of Corrections and a Compliance Order.

This record of poor care stretches back to when Southbridge bought Orchard Villa from its previous owner, Community Lifecare Inc., in 2015, during what Southbridge’s Chairman has called its “acquisition phase”. Southbridge does not have a history of operating LTC homes. It purchases and licenses homes in order to draw a return on its investment. As it notes on its website, Southbridge hires a management firm, Extendicare Canada Inc., “to manage the operations of our homes, both before and after redevelopment.” Extendicare is a for-profit LTC management company that trades on the TSX. Thus, investors are looking for a return on investment from two layers of Orchard Villa’s operations.

Southbridge is currently licensed for 233 long-term care beds at Orchard Villa. That license was initially granted in July 2010 to Community Lifecare Inc. from which Southbridge purchased the home as noted above. Southbridge is now proposing to develop 87 additional long-term care beds “conditionally allocated by the Ministry of Long-Term Care” to be included in the proposed 320-bed development project; and the issuance of a new license with a term of up to 30 years for the operation of 320 new beds at the existing location, following the development.

In summary, the record of care provided by Southbridge at Orchard Villa is appalling. Recorded observations by hospital staff, the Canadian Forces, inspections officers include the following:

  • Staffing levels at the home to be 20-25% of the normal complement, garbage “everywhere”, “very shocking” personal protective equipment (PPE) practices, and the absence of even rudimentary infection control measures. Just to “stabilize the situation,” Orchard Villa required a deep clean costing almost $500,000.”

Source: Ontario’s Long-Term Care COVID-19 Commission.

  • Poor infection control practices, including improper use of PPE; the presence of cockroaches, flies and rotting food; such inadequate resident care that residents were being left in soiled diapers, experienced falls without the post-fall assessments required by regulation, were the victims of medication administration errors, were not properly hydrated or sat up for meals (increasing their choking risk); a broad lack of medical supplies, including limited and/or inaccessible wound care supplies, linens and soaker pads, or properly functioning oxygen generators and suction units; residents being left on mattresses on the floor to prevent them from getting up and walking; significant shortcomings concerning incident reporting and communication between all levels of staff; and lack of training for staff and “[n]o accountability for staff in regards to upholding basic care needs or best practices”.

Source: Canadian Armed Forces.

  • Dire understaffing, poor management, and the absence of infection control procedures at the home, conditions that resulted in extreme weight loss, bed sores, infections and other harms.

Source: testimony of Orchard Villa families to Ontario’s Long-Term Care COVID-19 Commission.

  • Routine failure to follow falls protocols – even those resulting in injury and death for residents; failure to report abuse resulting in harm; failure to follow infection control protocols; failure to provide PPE to staff and ensure they use it even in recent months; failure to follow care plans and provide safe clinical care; failure to keep equipment in good operating order and to keep the home heated adequately in the winter.

Source: Inspection non-compliance reports, Ministry of Long-Term Care.

Given its long-standing record of regulatory non-compliance; its persistent failure to operate the Orchard Villa home in accordance with the law and with honesty; its demonstrable failure to operate Orchard Villa in a competent and responsible manner; and its chronic failure to protect the health, safety and welfare of its residents, the Applicant is clearly not eligible for a license to operate this long-term care home and its application for a license to do so must be denied.

Respectfully Submitted By:

Natalie Mehra

Executive Director

Ontario Health Coalition

15 Gervais Drive, Suite 201

Toronto, ON M3C 1Y8


Click here for printable version of submission

On October 13, the callout below was posted.

You may remember Orchard Villa. More than 70 of its residents died of COVID. It is where Diane Colangelo’s mom entered at 105 lbs and died at 68 lbs. It was where June Morrison’s dad died, and where Andrew Watt’s mom died so emaciated he described her as looking like a concentration camp victim. It is where the military was sent in and found residents using bare mattresses on the floor, the odour of rotting food, insect infestation and more.  It is owned by Southbridge, a for-profit chain with one of the very worst COVID death rates of all of them. Southbridge doesn’t actually run their long-term care homes. They are an investment vehicle from which to take profits. They contract Extendicare — another for-profit — to run them.

Orchard Villa is where Cathy Parkes and the Families of Orchard Villa took a brave public stand demanding accountability for the loss of their fathers and mothers, wives and husbands. We have supported them every step of the way. Please help again as the case of Orchard Villa winds its way to a conclusion.

On July 15, 2021, families and advocates flooded a public consultation telephone conference opposing the new 30-year license and bed expansion proposed for Orchard Villa. We had asked you to come out and you did!

But the Ministry turned the consultation into a sham, limiting participants from asking questions and preventing them from commenting on the corporation’s record operating the home, even cutting off participants who tried to ask about care levels.

We made a formal complaint and sent an open letter to the Long-Term Care Minister calling for a renewed, fair process that does not exclude consideration of the evidence about the corporation’s fitness to run a long-term care home for 30-years and for them to consider the criteria, including the operational record of the corporation in running the long-term care home, as was required under the Long-Term Care Homes Act.

As a result, the Ministry had to redo the consultation for Orchard Villa. The new consultation is taking place now. This time they are only accepting written submissions, there will be no hearing. We are strongly encouraging everyone to please send in your feedback on the proposal to give Orchard Villa a new 30-year license and bed expansion. The deadline for feedback is October 19 so make sure to send in your feedback as soon as possible.

We will be taking this issue forward and they need to see that Ontarians care. Please don’t forget to send in a note with your feedback before October 19.

There are two ways to provide feedback for this consultation:

  1. Share your feedback by email to
  2. Share your feedback by mail to:Director under the Fixing Long-Term Care Act, 2021
    Ministry of Long-Term Care
    Capital Planning Branch
    438 University Avenue, 8th Floor
    Toronto, Ontario M5G 2K8

Please make sure you include the name of the long-term care home (Orchard Villa) and quote Project #23-034 on all submissions.

Here is a bit more information and background for you:

The residents & families of Orchard Villa have suffered enough. For-profit chain Southbridge owns this long-term care home where 71 residents died of COVID-19 and others died of dehydration, starvation and horrific neglect. There has been NO accountability for the corporate owners, whose LTC homes have the worst death rate in Ontario. Southbridge doesn’t actually operate its LTC facilities. It owns the licenses and takes profit from it, but it contracts out the operations of the homes to another for-profit corporation to run. Two sets of for-profits make profits out of public funding and residents’ fees. While the for-profits in general have far worse pandemic death rates, Southbridge has the worst, according to an analysis by the Toronto Star.

In the spring of 2020, 206 residents out of 233 contracted COVID-19 along with more than 100 staff. At least seventy-one residents died as a result of the virus. Others died of malnutrition and dehydration. The Canadian Forces described the condition in which they found residents left in soiled sanitary pads and the home infested with cockroaches and flies. They also found rotten food, understaffing, poor training, inadequate medical supplies, locked supply cabinets, staff who had been brought in by that point from agencies and the hospital not oriented and unable to access supplies they needed. Residents were put on mattresses on the floor to prevent them from standing up and walking or had their walkers taken away, or left on bare mattresses without linens. Food and important belongings were left out of residents’ reach. Hydration schedules were not followed, medication errors were documented and infection control protocols were not upheld.

Families testified before the COVID-19 Long-Term Care Commission describing dire understaffing and poor management conditions that predated the pandemic by years, resulting in extreme weight loss, bed sores, infections and other harm. The families did not blame individual staff. They describe dangerously chronic low levels of staffing. During the pandemic families who were shut out of the home described phoning repeatedly but there was not enough staff to answer. One family, unable to get through by phone, watched through the window as their mother with COVID-19 vomited in her room with no staff around. They had to bang on the window until they could get staff to come and give their mother water. She died days later.

Eventually — terribly belatedly — the local hospital took over the management of the home from Extendicare, the company that Southbridge had contracted to run the facility. Residents who had survived until then were finally transported out to hospital where they were found to be severely dehydrated, anorexic from malnutrition, and some in kidney failure. A hospital spokesperson reported that the home had dropped to 20% of a full staffing complement.

Orchard Villa’s for-profit long-term care operator was never fined. It never lost its license. There has been no accountability for the unspeakable suffering of the residents and their families.

Quite the opposite. In the fall of 2020, the Ford government passed a law shielding Orchard Villa and the other for-profit long-term care home operators that were facing lawsuits for negligence, wiping out the claims of families who had lost their loved ones. The families had to start again and file suits for gross negligence which has a higher burden of proof.

Suffering and death on the scale that we saw at Orchard Villa requires an unmitigated “never again”. What happened at Orchard Villa should never have been allowed to happen. But since it did, it should have resulted in a reckoning – real change and real accountability. Instead, the owners are being rewarded.

The lives of the elderly cannot be treated as disposable. Profit and greed cannot be allowed to trump fundamental human rights and the duty to care and compassion.

We can and must stop these plans. If we do not, what kind of a society are we?

For all our members and supporters, our heartfelt thank you for your care and your compassion for the residents, their families and the workers. Let’s all do everything we can do to stop the Ford government from saddling Ontarians with another generation of for-profit long-term care.

We have this opportunity now to stop them. I will be taking the time to make a written submission. I cannot conscience doing any less. Please do join me.

With warm regards,

Natalie Mehra
Executive Director