Description: A licensee must ensure that each bedroom is directly accessible from a hallway without passing through any other room.

Corrective Actions Required: Ensure that each bedroom for the person in care is directly accessible from a hallway without passing through another room.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 15, 2021

Observations: Licensing observed that the bedroom for one person in care is directly accessible from the dining room/kitchen area. The facility had an exemption for this section of regulation, which expired on November 22, 2020. On April 26, 2021 the Licensee submitted an exemption request related to this contravention.

Description: A licensee who provides a type of care described as Long Term Care must provide for the number of persons in care on a floor and in the same wing indicated in column 1 of the following table, the number of bathing facilities indicated in column 2 opposite the number of persons in care: 3-6 (1) 7-25 (2) 26-40 (3) 41-60 (4) 61-75 (5)

Corrective Actions Required: Ensure that for 7 to 25 persons in care on a floor or in the same wing, there are two bathing facilities. The Licensee had an exemption for this section of legislation, which expired on November 22, 2020. On April 26, 2021, the Licensee submitted an exemption request related to this contravention.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 16, 2021

Observations: Licensing observed that there was one bathing facility on the floor and in the same wing for eight persons in care.

Description: A licensee must provide the following appropriately furnished and equipped areas: secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials

Corrective Actions Required: Ensure secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 15, 2021

Observations: Licensing observed that a container of Lysol cleaning wipes was stored on a shelf in the common area of the facility, accessible to persons in care.

Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: character references in respect of the person

Corrective Actions Required: Ensure the character references are obtained for each staff person.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 27, 2021

Observations: Licensing observed three staff files. Two staff files did not contain character references.

Description: The licensee must take all reasonable steps to ensure that the food served to persons in care follows the menu and, if unable to do so because of unforeseen circumstances, that the food provided to persons in care meets the nutritional requirements set out in subsection (2).

Corrective Actions Required: Ensure all reasonable steps are taken to ensure the food served to persons in care follows the menu.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 15, 2021

Observations: Licensing observed a posted menu and a document of the actual items served at the facility for the current month of May 2021. Menu items and protein sources that were documented as served did not align with any of the weeks outlined on the posted menu.

Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable

Corrective Actions Required: Ensure to obtain and keep consent for persons in care to be admitted or continue to be accommodated in the community care facility, in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1of this regulation, as applicable.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 15, 2021

Observations: Licensing reviewed two files for persons in care. Both persons in care were admitted after November 2019, and neither file contained consent to be admitted to the community care facility, in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1of this regulation, as applicable.

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: Ensure that each person in care's record, there is 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 Taken By Licensee:

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

To Be Corrected By: June 15, 2021

Observations: Licensing observed files for two persons in care and neither file contained records of consent from the person in care or parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.