Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care

Corrective Actions Required: Ensure that the community care facility is operated in a manner that will promote the health, safety, and dignity of persons in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: August 14, 2025

Observations: Licensing toured the facility and observed a container of bleach accessible to persons in care in the laundry area. Licensing also observed a fire exit in the bedroom of a person in care that was blocked with a table and the bottom part of a bed of a person in care.

Description: A licensee must keep the following records in respect of each employee: criminal record check results,

Corrective Actions Required: Ensure criminal record check results are kept for staff.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: September 19, 2025

Observations: This contravention was carried over from the Routine Inspection dated December 9, 2022. On this date Licensing audited four staff files and observed that one staff did not have a Criminal Record Check completed by the Province, and one staff had a Criminal Record Check that expired in February 2024.

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 each employee has records demonstrating compliance with the Province's immunization and tuberculosis control programs.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: September 19, 2025

Observations: This contravention was carried over from the Routine Inspection dated February 20, 2025. On this date Licensing audited four staff files and observed that three staff did not have a record of immunization, and one staff did not have a record of tuberculosis screening.

Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.

Corrective Actions Required: Ensure that all persons admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: September 19, 2025

Observations: This contravention was carried over from the Routine Inspection dated February 20, 2025. On this date, Licensing audited the records for four persons in care and observed that two persons in care did not have a record of immunization.

Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the care plans and records for three persons in care and observed that all persons in care had a record of consent, in writing, from the person in care or representative, to call a medical practitioner, nurse practitioner, or ambulance in case of accident or illness.

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

To Be Corrected By:

Observations:

Description: A care plan must include all of the following: if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan to prevent the person in care from leaving

Corrective Actions Required: Ensure that a care plan includes a plan to prevent the person in care from leaving, if the person in care has been determined to be at risk of leaving a community care facility without notification of an employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: August 14, 2025

Observations: Licensing audited the care plans for four persons in care who were deemed at risk for leaving a community care facility without notification of an employee, and all four persons in care did not have a plan to prevent them from leaving.

Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,

Corrective Actions Required: Ensure that each person in care is weighed at least once each month.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: August 14, 2025

Observations: Licensing audited the weight records for four persons in care and observed that three persons in care were missing weight records for both April and July 2025, and one person in care was missing weight records for April, June, and July 2025.

Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities suitable to the needs of the persons in care

Corrective Actions Required: Ensure that there is an ongoing plan of physical, social, and recreational activities suitable to the needs of persons in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: September 19, 2025

Observations: This contravention was carried over from the Routine Inspection dated February 20, 2025. On this date, Licensing audited the facility recreational calendar for August 2025. There was not a full calendar of ongoing planned activities.