Description: A licensee must ensure that the temperature in each bedroom, bathroom and common room is safe and comfortable for a person who is carrying out the types of activities that would be reasonably expected in the ordinary use of the room.

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing took the temperatures of five bedrooms and all five bedroom temperatures were under 25 degrees Celsius. Licensing observed multiple fans in the hallways and bedrooms operating and window blinds closed in bedrooms.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Required: Ensure that all employees comply with the policies and procedures of the medication safety and advisory commitee.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: October 3, 2025

Observations: Licensing audited the August 2025 Narcotics counts for three persons in care. On August 2, 2025, there was no 2:30 p.m. count completed and on August 11, 2025, there was no 10:30 p.m. count completed for three persons in care. Licensing confirmed the count was to be completed at 6:30 a.m., 2:30 p.m. and 10:30 p.m. by staff.

Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,

Corrective Actions Required: Ensure that staff comply with the Province's immunization and tuberculosis control program.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: October 3, 2025

Observations: Licensing reviewed fourteen staff files. Four staff files did not have a copy of tuberculosis test results and two staff did not have a record of immunization.

Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care

Corrective Actions Required: Ensure that in the case of a person in care who is prone to falling, there is a fall prevention plan which includes a plan for following up on falls suffered by the person in care.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: August 31, 2025

Observations: Licensing reviewed five person in care care plans who were at risk for falls. Two care plans did not have a plan to address falls suffered by the persons in care.