Complaint Investigation

Inspection Information

Facility Type

Residential Care - 400

Received Date

24-Jul-2024

Subject

["Neglect","Dispute Resolution","Reporting (Includes issues such as not reporting, insufficient reporting, etc.)","Medication (Includes issues such as missing, inappropriate use/overuse of medications, errors, etc.)","Staffing (Includes issues such as suitability, insufficient levels, etc.)","Recordkeeping (Includes issues such as not keeping records, insufficient records, care planning issues, health care consent, admission records.)","Suitability of Manager or Suitability of Licensee"]

Contraventions: A summary of the new contraventions found during the inspections are listed below.

Code

Category/Description

Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer

Observation: Through the investigation process, Licensing determined that a person in care was involved in a reportable incident, and the licensee did not immediately notify a medical health officer, in the form and in the manner required by the medical health officer.

Corrective action: Ensure that if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On September 17 and 23, 2024 and October 16, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that staff received education on the incident reporting policy and were made aware that allegations of neglect were to be reported to Licensing. The corrective action plan was reviewed and accepted by Licensing. On October 7, 2024, Licensing received confirmation that the education had been completed.

A licensee, other than a licensee who provides a type of care described as Child and Youth Residential, must ensure that an evening meal is served after 5:00 p.m., and

Observation: Through the investigation process, Licensing determined that the Licensee did not ensure that an evening meal was served after 5:00 p.m.

Corrective action: Ensure that an evening meal is served after 5:00 p.m. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On September 17 and 23, 2024, and October 16, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that the facility had changed dinner service to be served after 5:00 p.m. The corrective action plan was reviewed and accepted by Licensing. On January 21, 2025, Licensing received a written statement from the Licensee Contact, which stated that dinner was not served until 5:00 p.m. and communication regarding the mealtimes had been provided to the culinary team and care aides.

A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including a safe, secure place in which the person in care may store valuable property

Observation: Through the investigation process, Licensing determined that the licensee did not provide, at no cost to the person in care, bedroom furnishings, including a safe, secure place in which the person in care may store valuable property.

Corrective action: Ensure that the licensee provides, at no cost to the person in care, bedroom furnishings, including a safe, secure place in which the person in care may store valuable property. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On September 17 and 23, 2024 and October 16, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included the Resident Handbook and Tenancy Agreement were updated to indicate that bedroom furnishings were available, and the Manager reviewed options for furnishings at the time of admission and leaders received education on the requirements set out by Legislation regarding bedroom furnishings. The corrective action plan was reviewed and accepted by Licensing. On October 31, 2024, Licensing received the updated Resident Handbook and confirmation that the education had been completed and the updated Tenancy Agreement was to be completed by December 1, 2024.

A licensee must do all of the following: ensure that policies are implemented by employees.

Observation: Through the investigation process, Licensing determined that policies were not implemented by employees. Specifically, related to the complaint policy.

Corrective action: Ensure that policies are implemented by employees. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On September 17 and 23, 2024 and October 16, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included all complaints were entered into the complaint platform where they were reviewed by the Manager and all leaders were education on the Complaint Policy. The corrective action plan was reviewed and accepted by Licensing. On October 7, 2024, Licensing received confirmation that the education was completed.