Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.

Corrective Actions Required: Ensure that all water sources accessible to persons in care, from any source, is not heated to more than 49 degrees Celsius.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 23, 2025

Observations: Licensing audited the water temperature in the bathrooms of 21 persons in care's bedrooms. Four of the persons in care's bedrooms sink water temperature average reading was 52 Degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. The Manager stated the issue would be discussed with maintenance by December 18, 2025. Full compliance will not be achieved until the plan has been implemented and completed.

Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation,

Corrective Actions Required: Ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 17, 2026

Observations: Licensing audited 20 staff files. Five staff files did not contain current Performance Evaluations.

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

Corrective Actions Required: Ensure all staff files contain current criminal record check results.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 23, 2025

Observations: Licensing audited 20 staff files. Two staff files did not contain current criminal record check results.

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 an assessment of the nature of the risk of falling presented by the person in care

Corrective Actions Required: Ensure that all persons in care have a fall prevention plan which addresses an assessment of the nature of the risk of falling presented by the person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 14, 2026

Observations: Licensing audited 15 person in care's care plans. Four persons in care's care plans did not contain an assessment of the nature of the risk of falling presented by the person in care.

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 17, 2026

Observations: Licensing audited 15 person in care's care plans and records. Four persons in care did not have a weight documented at least once a month. One person in care was missing five consecutive months of weight records.