Description: A licensee must not permit an employee to carry out any duties for which the employee does not have the necessary training and experience or demonstrate the necessary competence.

Corrective Actions Required: Ensure that staff do not carry out any duties for which they do not have the necessary training and experience, or have demonstrated the necessary competence to do so. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On May 30, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: the Licensee would create a protocol for off-duty nursing responsibilities by June 30, 2025, for any emergencies involving persons in care, Registered Care Aides (RCAs) were to call 9-1-1 and the Nurse could be contacted by phone when off-duty on an on-call basis for any concerns, questions, or guidance, RCAs did not have the training or scope to conduct nursing assessments, and the policy was updated in March 2025 to have vital signs as a nursing staff tasks, RCAs would no longer take vital signs of persons in care. The corrective action plan was reviewed and accepted by Licensing.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 25, 2025

Observations: Regarding intake dated March 14, 2025. Through the investigation process, Licensing determined that staff carried out duties for which they did not have the necessary training and experience for; specifically related to taking and monitoring of vitals of persons in care.

Description: A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of the persons in care,

Corrective Actions Required: Ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of the 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 May 30, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: the Licensee would create a protocol for off-duty nursing responsibilities by June 30, 2025, for any emergencies involving persons in care, Registered Care Aides (RCAs) were to call 9-1-1 and the Nurse could be contacted by phone when off-duty on an on-call basis for any concerns, questions, or guidance, RCAs did not have the training or scope to conduct nursing assessments, and the policy was updated in March 2025 to have vital signs as a nursing staff tasks, RCAs would no longer take vital signs of persons in care, a list of RCAs with medication administration training certification would be completed by June 15, 2025, Nurses would observe and review each RCA's medication administration practices and provide targeted medication administration training by June 30, 2025, and the Licensee would offer additional medication administration training. The corrective action plan was reviewed and accepted by Licensing.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 25, 2025

Observations: Regarding intake dated March 14, 2025. Through the investigation process, Licensing determined that the employees on duty were not sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of the persons in care.

Description: A licensee must ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C,

Corrective Actions Required: Ensure that, at all times, persons in care have immediate access to a staff who holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On May 30, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: On May 30, 2025 a reminder was added to the staff communication binder that stated Registered Care Aides (RCAs) were to plan accordingly to complete first aid and CPR courses ahead of the expiring dates and a list of first aid and CPR certificate expiry dates was compiled for all staff to ensure all certificates were current. The corrective action plan was reviewed and accepted by Licensing.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 25, 2025

Observations: Regarding intake dated March 14, 2025. Through the investigation process, Licensing determined that persons in care did not have, at all times, immediate access to a staff who held a valid first aid and CPR certificate, provided on completion of a course that met the requirements of Schedule C.

Description: A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) 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. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On May 30, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: Room and safety check procedures were implemented in November 2024, and the shift task-list for staff included completion of the room and safety checks each shift with documentation of those checks, a Nurse would review the room and safety check sheets and communication binder charting from previous shifts and would follow-up on any missed documentation by writing in the staff communication book, the Care Plan for a person in care was updated related to room and safety checks, and highlighted their suicidal ideation risk, communication was provided to staff on May 30, 2025, to review the person in care's updated Care Plan, and a reminder to perform and document room and safety checks every shift. The corrective action plan was reviewed and accepted by Licensing.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 25, 2025

Observations: Regarding intake dated March 14, 2025. 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; specifically related to documentation.