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 all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 17, 2026

Observations: Licensing audited eight person in care's Medication Administration Records (MARs). All MAR's included medication creams and ointments which were not signed and/or coded for by staff on multiple dates, as required by policy.

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 that the community care facility is operated in a manner that promotes 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: April 17, 2026

Observations: Licensing toured seven person in care's bedrooms and observed a cleaning agent, under one person in care's sink.

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: June 18, 2026

Observations: Licensing audited eight person in care's records. Four person in care's weights were not recorded for multiple months, over the past year.

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

Corrective Actions Required: Ensure that records kept include character references, in respect of each employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 17, 2026

Observations: Licensing audited nine employee files and observed one employee file had no character references.

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 that a community care facility is operated in a manner that promotes 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: April 17, 2026

Observations: Licensing observed six persons in care, residing in double rooms in room numbers 226, 249 and 222. Review of the facility file indicated there was an approved exemption to Residential Care Regulation, Section 25(2)(a) with the following condition: Specific to bedrooms numbered 201, 206 and 221 only, that was approved February 24, 2026.

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 was returned to the dispensing pharmacy if the expiry date has passed.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 17, 2026

Observations: Licensing audited the facility's medication cabinet on the first floor and observed one person in care's medication had expired in October 2025.