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. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the Union that the staff was a member of had been contacted to request guidance on a plan of action if the staff was unfit to work, and the licnesee was awaiting a response, if the staff was unfit for work or displayed unsafe behaviours, they would be asked to go home and a casual staff would be called-in to cover the shift, and the facility was actively recruiting additional casual staff for contingency planning. As a result of two Final Summary Reports of Investigation, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection process.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 31, 2025

Observations: Regarding intake dated October 30, 2024. Through the investigation process, Licensing determined that a staff did not demonstrate the skills and abilities necessary to carry out the duties as assigned.

Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Required: Ensure that staff comply with the policies and procedures of the medication safety and advisory committee. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the facility was seeking additional support from the pharmacy for increased accountability and best practices for eMAR use, a clinical staff would review the medication administration policy by the end of January 2025, and additional medication administration training would be completed for Registered Care Aides (RCAs) by the end of March 2025. As a result of two Final Summary Reports of Investigation, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection process.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 31, 2025

Observations: Regarding intake dated October 30, 2024. Through the investigation process, Licensing determined that staff did not comply with the policies and procedures of the medication safety and advisory committee.

Description: A licensee must do all of the following: ensure that policies are implemented by employees.

Corrective Actions Required: Ensure that policies are implemented by staff. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the Manager and Assistant Nursing Manager would review all policies by January 15, 2025, and highlight any areas needing revision, all staff would review and initial the policy related to substance use and being fit for work by the end of January 2025. As a result of two Final Summary Reports of Investigation, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection process.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 31, 2025

Observations: Regarding intake dated October 30, 2024. Through the investigation process, Licensing determined that a staff did not implement policies.

Description: A licensee must do all of the following: operate the community care facility in a manner that will promote in the case of adult persons in care, the rights of those persons in care;

Corrective Actions Required: Ensure the community care facility is operated in a manner that will promote the rights of adult 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 December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: menstruation products were purchased in October 2024 for all persons sin care who required them, and the Registered Care Aides (RCAs) were advised where the products were located. As a result of two Final Summary Reports of Investigation, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection process.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 31, 2025

Observations: Regarding intake dated October 30, 2024. Through the investigation process, Licensing determined that the facility was not operated in a manner that promoted the rights of persons in care.

Description: A licensee must ensure that a person in care is not, while under the care or supervision of the licensee subjected to any of the following types of abuse or neglect, as described in section 1 of Schedule D: emotional abuse

Corrective Actions Required: Ensure that persons in care are not subjected to emotional abuse. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the Union that the staff was a member of had been contacted to request guidance on a plan of action if the staff was unfit to work, and the licensee was awaiting a response, if the staff was unfit for work or displayed unsafe behaviours, they would be asked to go home and a casual staff would be called-in to cover the shift, and the licensee was actively recruiting additional casual staff for contingency planning. As a result of two Final Summary Reports of Investigation, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection process.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 31, 2025

Observations: Regarding intake dated October 30, 2024. Through the investigation process, Licensing determined that persons in care were subjected to emotional abuse.

Description: Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer

Corrective Actions Required: Ensure the Licensee immediately notifies a medical health officer when a person in care is involved in a reportable incident. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: staff were asked to review an Incident Reporting policy and confirm via signature that the policy was reviewed, and as of January 6, 2025, the policy had been reviewed "by the majority of staff", and the remaining staff would sign the policy by end of January 2025, all new staff must be trained on the Incident Reporting policy to ensure complaince. As a result of two Final Summary Reports of Investigation, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection process.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 31, 2025

Observations: Regarding intake dated October 30, 2024. Through the investigation process, Licensing determined that the Licensee did not immediately notify a medical health officer when a person in care was involved in a reportable incident.

Description: A care plan must include all of the following: a plan to address behavioural intervention, if applicable

Corrective Actions Required: Ensure a care plan addresses behavioural interventions. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: All Care Plans would include behavioural interventions specific to each person in care, based on their history and diagnoses, in November 2024 all charts for persons in care were reviewed and updated for key care plan safety items, including advanced care plans. As a result of two Final Summary Reports of Investigation, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection process.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 31, 2025

Observations: Regarding intake dated October 30, 2024. Through the investigation process, Licensing determined that a care plan did not include a behavioural intervention.

Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan

Corrective Actions Required: Ensure care plans are reviewed and, if necessary, modified if there is no substantial change of the person in care, at least once each year. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: In November 2024, all charts for persons in care were reviewed and updated for key care plan safety items, the Manager and/or Assistant Nursing Manager would complete a detailed review of each care plan and sign using a tracking sheet by the end of January 2025, starting on January 1, 2025, the facility would send requests to healthcare providers on an ongoing basis, for updates following appointments to update the staff on the status or need to update the care plan for the persons in care. As a result of two Final Summary Reports of Investigation, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection process.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 31, 2025

Observations: Regarding intake dated October 30, 2024. Through the investigation process, Licensing determined that care plans were not reviewed, and modified, when there was a substantial change in the circumstances of the person in care.

Description: A licensee must ensure that a pharmacist packages all medications

Corrective Actions Required: Ensure that a pharmacist packages all medications. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: A formal room-check procedure was implemented in November 2024, with a flowsheet for staff to document every shift related to comfort checks and room checks, any over the counter medications found had been documented and confiscated as required. As a result of two Final Summary Reports of Investigation, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection process.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 31, 2025

Observations: Regarding intake dated October 30, 2024. Through the investigation process, Licensing determined that a pharmacist did not package all medications.

Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.

Corrective Actions Required: Ensure that a person in care's medication is returned to the dispensing pharmacy if the expiry date on the medication has passed. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 20, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan was reviewed and not accepted by Licensing. On December 27, 2024 and January 6, 2025, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: On December 12, 2024, the Manager reviewed all PRN [as needed] and narcotic medications in the medication cart for outdated prescriptions and expired medications, and a tracking template was created, which the facility would use at the end of each month to check for expired and outdated PRN and narcotic medications on an ongoing basis. As a result of two Final Summary Reports of Investigation, prepared by Licensing, the Medical Health Officer imposed conditions on the licence of Shelmarie Rest Home on October 3, 2025. Licensing will continue to work with the Licensee and monitor the facility's compliance with the Community Care and Assisted Living Act and the Residential Care Regulation. Licensing will continue to follow up on the areas identified in the Final Summary Reports of Investigation through the Routine Inspection process.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 31, 2025

Observations: Regarding intake dated October 30, 2024. Through the investigation process, Licensing determined that a person in care's medication was not returned to the dispensing pharmacy when the expiry date on the medication had passed.