Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year

Corrective Actions Required: Ensure that policies and procedures are reviewed, and if necessary revised, at least once each year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 4, 2026

Observations: Licensing audited the policies and procedures and all except two had not been reviewed at least once per year.

Description: A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province’s immunization and tuberculosis control programs.

Corrective Actions Required: Ensure that a person employed in a community care facility provides to the licensee evidence of continued 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: February 4, 2026

Observations: This item was carried forward from Routine Inspection dated October 2, 2024. Licensing was unable to confirm evidence of continued compliance with the Province's immunization and tuberculosis programs for employees, as records were not available.

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 programs.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 4, 2026

Observations: Licensing audited five records of persons in care and three did not contain evidence of compliance with the Province's immunization program.

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 a plan for following up on any falls suffered by a person in care

Corrective Actions Required: Ensure that if a person in care who receives a type of care described as Long Term Care or who may be prone to falling, has a fall prevention plan that addresses a plan for following up on any falls suffered by the person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 4, 2026

Observations: This item has been carried forward from Routine Inspection dated October 2, 2024. Licensing audited five records of persons in care and none contained a plan on follow up to any falls suffered by the person in care.