Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
28-Mar-2024
Subject
["Release/Removal of Persons in Care","Rights of Adult Persons in Care"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must do all of the following:(b) operate the community care facility in a manner that will promote 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 will promote the health, safety, and dignity of persons in care.
Corrective action: Ensure to operate the community care facility in a manner that will promote the health, safety, and dignity of persons in care. A
To be corrected by: 31-Dec-2024
A licensee must operate the community care facility in a manner that will promote 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 will promote the health, safety, and dignity of persons in care.
Corrective action: Ensure to operate the community care facility 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 to Licensing specific to the contravention. Action/s Required by Licensing: On June 6, 2024, the manager submitted a corrective action plan to Licensing. The corrective action plan included a prohibition for the recreation aide to work in the LTC unit for an additional six months, ending December 31, 2024; continued weekly meetings to discuss programming; another self reflection written by the recreation aide to demonstrate learning; recreation aide to work out of an office in the administration area; if the recreation aide comes across an LTC person in care in the Assisted Living, rec aide to stay with them, call responder to assist the person back to LTC; performance review for the rec aide at the conclusion of the corrective action plan; goals to be set by recreation aide, and review of her status to work in LTC would be completed after December 31, 2024.This corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan.
To be corrected by: 31-Dec-2024
A licensee must operate the community care facility in a manner that will promote 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 will promote the health, safety, and dignity of persons in care. Specifically, that staff did not follow policy related to removing a person in care from the unit.
Corrective action: Ensure to operate the community care facility 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 to Licensing specific to the contravention. Action/s Required by Licensing: On June 6, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that the staff was not to work in the LTC unit for an additional six months, ending December 31, 2024, the staff was to write a self-reflection about what they had learned over the past six months and their performance was to be reviewed at the end of the timeline with the completion of set goals and action plans. The corrective action plan was reviewed and accepted by Licensing. On July 7, 2025, Licensing confirmed with the Manager that all corrective action plan items had been completed by the employee, who has since resigned as of April 29, 2025.
A licensee must operate the community care facility in a manner that will promote 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.
Corrective action: Ensure to operate the community care facility 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 to Licensing specific to the contravention. Action/s Required by Licensing: On June 6, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that the staff was not to work in the LTC unit for an additional six months, ending December 31, 2024, the staff was to write a self-reflection about what they had learned over the past six months and their performance was to be reviewed at the end of the timeline with the completion of set goals and action plans. The corrective action plan was reviewed and accepted by Licensing. On July 7, 2025, Licensing confirmed with the Manager that all corrective action plan items had been completed by the employee, who has since resigned as of April 29, 2025.
A licensee must operate the community care facility in a manner that will promote 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 will promote the health, safety, and dignity of persons in care. Specifically, a staff did not demonstrate the skills and abilities necessary to carry out the duties assigned.
Corrective action: Ensure that the community care facility is operated in a manner that promotes the health, safety and dignity of 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 June 6, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that the staff was not to work in the LTC unit for an additional six months, ending December 31, 2024, the staff was to write a self-reflection about what they had learned over the past six months and their performance was to be reviewed at the end of the timeline with the completion of set goals and action plans. The corrective action plan was reviewed and accepted by Licensing. On July 7, 2025, Licensing confirmed with the Manager that all corrective action plan items had been completed by the employee, who has since resigned as of April 29, 2025.