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 water accessible to a person 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: April 1, 2026

Observations: Licensing tested the water temperature for 25 person in care's bathroom sinks. Three of the 25 person in care's bathroom sinks had a water temperature readings of 52.7 degrees Celsius and 55 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. A verbal plan for corrective action was submitted to Licensing on April 1, 2026, by the Manager, who stated they would contact maintenance staff to fix this issue on today's date, and would monitor the water temperatures to ensure safety of persons in care. Full compliance will not be achieved until the plan has been implemented and completed.

Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair

Corrective Actions Required: Ensure that all rooms and common areas are maintained in a good state of repair.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 1, 2026

Observations: Licensing toured the facility and observed that there was damage to a railing on the third floor, and wall and doorframe damage to two bedrooms on the sixth floor.

Description: A licensee must ensure that all medications in the community care facility are safely and securely stored,

Corrective Actions Required: Ensure that all medications in the community care facility are safely and securely stored.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 1, 2026

Observations: Licensing toured the facility and observed medications that were not safely and securely stored in one bedroom on the first floor, and one bedroom on the third floor.

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 1, 2026

Observations: Licensing audited the electronic Medication Administration Record (eMAR) for persons in care and observed that one person in care did not have a medication signed or coded for by staff on March 12, 2026, and another person in care did not have a medication signed or coded for by staff on March 19, 2026 as required by policy.

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 all policies and procedures at least once each year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 1, 2026

Observations: Licensing audited the policies and procedures for the facility and observed that all required policies had not been reviewed in the past year.

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 fall prevention plans include a plan for following up on any falls suffered by a person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 1, 2026

Observations: Licensing audited the care plans and records for 25 persons in care and observed that three persons in care did not have a fall prevention plan which addressed a plan for following up on any falls suffered.

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 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 Taken By Licensee:

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

To Be Corrected By: May 1, 2026

Observations: Licensing audited the care plans and records for 25 persons in care and observed that three of the care plans had not been reviewed within the past year.

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

Corrective Actions Required: Ensure that a pharmacist packages all medications.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 1, 2026

Observations: Licensing toured the facility and observed that there were two medications in the bedrooms of persons in care that were not packaged by a pharmacist, and there were several pills in the medication cart as well as medications in the fridge on the third floor that were not packaged by a pharmacist.