Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
20-Aug-2024
Subject
["Neglect","Recordkeeping (Includes issues such as not keeping records, insufficient records, care planning issues, health care consent, admission records.)","Nutrition and Food Service (Includes issues such as consistency, quantity, quality, feeding assistance, timing, etc.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: Through the investigation process, Licensing determined that a care plan was not developed by the Licensee for a person in care who was admitted to the community care facility for a period of more than 30 days.
Corrective action: Ensure that if a person in care is admitted to the community care facility for a period of more than 30 days, a licensee develops a care plan for the person in care in accordance with this section within 30 days of admission. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: In November 2024, all care plans for persons in care were reviewed and information updated; the Manager created their own care plan template to match the needs of persons in care at the facility and Licensing requirements; a detailed review of all care plans would be completed by end of January 2025; all staff would review all updated care plans by March 2025. As a result of two Final Summary Report of Investigations, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection Process.
To be corrected by: 28-Nov-2025
A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Through the investigation process, Licensing determined that employees did not comply with the policies and procedures of the medication safety and advisory committee.
Corrective action: Ensure that employees comply with the policies and procedures of the medication safety and advisory committee. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the Manager contacted the Care Aide Registry for consultation related to Insulin administration, narcotic administration, and taking blood pressure vitals; the Licensee was currently seeking additional support from the pharmacy for increased accountability and best eMAR use, all clinical staff would review medication administration policies by the end of January 2025 and additional training would be provided to Registered Care Aides (RCAs) related to multiple medication processes, naloxone administration, and Insulin assistance by the end of March 2025. As a result of two Final Summary Report of Investigations, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection Process.
To be corrected by: 28-Nov-2025
A licensee must ensure that each menu provides a variety of foods, taking into consideration the nutrition plan of each person in care and the nutrition needs, age, gender and level of activity of the persons in care
Observation: Through the investigation process, Licensing determined that the menu did not provide a variety of foods, taking into consideration the nutrition plan of each person in care and their nutritional needs.
Corrective action: Ensure that each menu provides a variety of foods, taking into consideration the nutrition plan of each person in care and the nutrition needs. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the Cook would refer to Canada's Food Guide and resources when developing the menu; meal plans would be reviewed for dietary adherence; two checks would be completed per month to ensure meals were prepared as planned. As a result of two Final Summary Report of Investigations, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection Process.
To be corrected by: 28-Nov-2025
A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.
Observation: Through the investigation process, Licensing determined that the care and supervision of persons in care was not consistent with the terms and conditions of the person in care's care plan.
Corrective action: Ensure that the care and supervision of persons in care is consistent with the terms and conditions of the person in care's care plan. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: In November 2024, all care plans for persons in care were reviewed and information updated; the Manager created their own care plan template to match the needs of persons in care at the facility and Licensing requirements; a formal room-check procedure was implemented in November 2024; a detailed review of all care plans would be completed by end of January 2025 and all staff would review all updated care plans by March 2025. As a result of two Final Summary Report of Investigations, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection Process.
To be corrected by: 28-Nov-2025
A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada’s Food Guide and the person in care’s nutrition plan.
Observation: Through the investigation process, Licensing determined that a person in care did not receive adequate food to meet their personal nutritional needs.
Corrective action: Ensure that persons in care receive adequate food to meet their personal nutritional needs. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: there was ongoing communication with the Cook about providing the prescribed low FODMAP diet to a person in care; the Cook would refer to resources when developing the menu; consultation with a Dietitian would be completed by the end of January 2025; meal plans would be reviewed for dietary adherence; two checks would be completed per month to ensure meals were prepared as planned. As a result of two Final Summary Report of Investigations, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection Process.
To be corrected by: 28-Nov-2025
A licensee must ensure that each menu provides for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada’s Food Guide,
Observation: Through the investigation process, Licensing determined that the menu did not provide nutritious morning, noon, and evening meals.
Corrective action: Ensure that the menu provides nutritious morning, noon, and evening meals. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the Cook would refer to Canada's Food Guide and resources when developing the menu; two checks would be completed per month to ensure meals were prepared as planned. As a result of two Final Summary Report of Investigations, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection Process.
To be corrected by: 28-Nov-2025
A licensee must ensure that a person in care is not, while under the care or supervision of the licensee subjected to any of the following types of abuse or neglect, as described in section 1 of Schedule D: neglect
Observation: Through the investigation process, Licensing determined that persons in care were subjected to neglect.
Corrective action: Ensure that a person in care is not, while under the care or supervision of the licensee, subjected to neglect. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: regular wound assessments were completed by the Manager and physician, the care plan for a person in care was updated to include physical and mental nursing assessments every three months; any communication related to the risks of wounds occurring for the person in care would be communicated with the person in care's physician and addressed accordingly. As a result of two Final Summary Report of Investigations, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection Process.
To be corrected by: 28-Nov-2025
A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Observation: Through the investigation process, Licensing determined that the licensee did not operate the community care facility in a manner that promoted the health, safety, and dignity of persons in care; specifically related to documentation.
Corrective action: Ensure that the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: a formal room-check procedure was implemented in November 2024, every Sunday, Registered Care Aides (RCAs) would sign-off on glucometer and aero chamber checks and the Manager would remind staff via the communication log to document room-checks, including items that were confiscated, significant interactions with persons in care, and reasons for PRN [as needed] medication administration. As a result of two Final Summary Report of Investigations, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection Process.
To be corrected by: 28-Nov-2025