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 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: February 9, 2026

Observations: This contravention was carried over from the Routine Inspection dated August 14, 2025. On this date Licensing toured the facility and observed several jugs of bleach not securely stored and accessible to persons in care. In addition, Licensing observed that non-emergency exit windows on the top floor of the facility could be opened completely, and Licensing was informed that a person in care had been smoking out of the window, posing a risk to persons in care.

Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair

Corrective Actions Required: Ensure all rooms and common areas are maintained in a good state of repair.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 13, 2026

Observations: Licensing toured the facility and observed that there were visibly soiled carpets on the staircase, there were empty cans outside the facility's entrance, there were curtains which had been ripped off their track and ripped apart, and there was a general lack of cleanliness.

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

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited four staff files and records and observed that all staff had Criminal Record Check results kept on-file.

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

To Be Corrected By:

Observations:

Description: A licensee must keep the following records in respect of each employee: character references

Corrective Actions Required: Ensure that character references are kept on file for each employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 13, 2026

Observations: Licensing audited four staff files and records and observed that two staff did not have character references kept on file.

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 all employees 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: March 13, 2026

Observations: This contravention was carried over from the Routine Inspection dated February 20, 2025. On this date Licensing audited four staff files and records and observed that two staff did not have records of compliance with both the Province's immunization and tuberculosis control programs.

Description: A licensee must ensure that each menu provides a variety of foods, taking into consideration the texture, colour and matters that affect food safety, taste and visual appeal,

Corrective Actions Required: Ensure that each menu provides a variety of foods, taking into consideration the texture, colour and matters that affect food safety, taste and visual appeal.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 13, 2026

Observations: Licensing audited the menus for the facility and observed that all four of the weekly menus had "toast" for breakfast, and there was not sufficient variety of foods for the meals and snacks each week.

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:

Corrective Actions Taken By Licensee: Licensing audited the care plans and records for four persons in care and observed that all persons in care had records of immunization kept on file.

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

To Be Corrected By:

Observations:

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: March 13, 2026

Observations: This contravention was carried over from the Routine Inspection dated August 14, 2025. On this date Licensing audited the monthly weights for November and December 2025 and January 2026, and observed that three persons in care were missing weight records for November 2025 and January 2026, and six persons in care were missing weight records for December 2025.

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 the community care facility is operated in a manner that will promote the health, safety, and dignity of persons in care; specifically, that the terms and conditions on the licence are followed.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 9, 2026

Observations: Related to the terms and conditions on the licence, on today's date, Licensing discussed the conditions on the licence with the Manager. Related to Condition 2: Licensing audited the staff schedule and observed that one nursing professional, other than the Manager, worked for 12 hours per week. The Manager confirmed that they had a Registered Nurse (RN) who worked 12 hours per week on-site, which did not meet the required 20 hours per week on-site, according to the condition. Related to Condition 3: The Manager stated that not all Registered Care Aides (RCAs) who administered medications had completed an additional Medication Assistant Certification training program. In addition, Licensing had not received any information related to courses and was therefore yet to approve any Medication Assistant Certification training program prior to staff enrollment, as per the condition. Related to Condition 5: The Manager stated that there were two persons in care who required diabetic diets who were assessed as needing such prior to their admission. The Manager stated that there had not been any Dietitian or Nutritionist consultations for the two persons in care since their admission. Licensing requested an immediate plan to be submitted to Licensing regarding noncompliance with the conditions on the licence.