Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
13-Jun-2024
Subject
["Health and Safety"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must operate the community care facility in a manner that will promote in the case of adult persons in care, the rights of those persons in care
Observation: Through the Licensing investigation process, Licensing determined that the licensee did not ensure that the facility was operated in a manner that promoted the rights of persons in care. Specifically, that a person in care did not feel safe in their environment because of the actions of other persons in care.
Corrective action: Ensure that the facility is operated in a manner that promotes the rights of all persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On August 13, 2024 and November 5 and 8, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: All staff were to complete a review on Code White (Aggression) and the Long-Term Care Licensing learning modules, which included a review of safe and secure environments for persons in care, and a review of the enhanced safety measures implemented at the facility, which included supporting persons in care to move away from an area that could impact their safety by September 30, 2024, starting October 1, 2024, staff are to participate in annual reviews of Code White practices, which included a debrief from person in care, open lines of communication with persons in care and their families would continue, the creation of a temporary (6 months) SPU Behavioural Support Attendant to mitigate safety risks was developed, the expansion of Protection Services Officer (PSO) presence from the previous 12-hour coverage to full 24/7 coverage was implemented and they were to conduct regular rounds of common areas every 30-60 minutes, the PSO team consists of two officers and a Safe Walk program was implemented with support from PSO. The corrective action plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. On November 5, 2024, Licensing conducted a Routine Follow Up Inspection and toured the first floor unit. The Licensee relocated their office to the facility to maintain a presence on site and conduct multiple daily rounds of the lobby and first floor units. On March 7, 2025, the Licensee submitted a copy of completed staff training of the Code White and Long-Term Care Licensing learning modules, confirmed that all of the Protection Services Officers completed required training including workplace violence prevention and mental health response strategies, and the PSOs were maintaining 24/7 coverage and providing a Safe Walk program.
A licensee must ensure that the policy required under subsection (3) is consistent with the prohibitions and restrictions under the Cannabis Control and Licensing Act or the Tobacco and Vapour Products Control Act, as applicable.
Observation: Through the Licensing investigation process, Licensing determined that the licensee did not ensure that the policy was consistent with the prohibitions and restrictions under the Cannabis Control and Licensing Act or the Tobacco and Vapour Products Control Act.
Corrective action: Ensure that the policy is consistent with the prohibitions and restrictions under the Cannabis Control and Licensing Act or the Tobacco and Vapour Products Control Act. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On August 13, 2024 and November 5 and 8, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: all security staff would complete Relational Security training by September 30, 2024, the creation of a SPU Behavioural Support Attendant (BSA) was developed to support compliance with safety policies, particularly around managing prohibited items (such as fire starters), smoking regulations, and reducing exposure to second-hand smoke, the installation of lighter poles on the outdoor space to help reduce persons in care carrying their own lighters was implemented and the revised guideline Safe Tobacco/Cannabis Smoking and Vaping: Long-term Care and prepared informative posters for display was to be shared at the family meeting on November 20, 2024. This corrective action plan has been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. On November 5, 2024, Licensing conducted a Routine Follow Up Inspection and observed on the first floor units outdoor space a yellow painted line for persons in care to smoke beyond and observed the installed lighter poles to reduce persons in care carrying their own lighters, the Licensee relocated their office to the facility to maintain a presence on site and conduct multiple daily rounds of the lobby and first floor units. On January 16, 2025, the Licensee proposed an installation of a non-structural wind break to provide additional protection and improve air quality. On February 13, 2025, Licensing conducted a Routine Inspection and observed the addition of a non- structural wall to the outside first floor wall to improve air quality. On March 7, 2025, the Licensee confirmed that all of the Protection Services Officers completed required training including workplace violence prevention and mental health response strategies by September 30, 2024.