24th Avenue

Confidential · Residential Care - Licensing

9 inspections

1. Routine InspectionSep 23, 2026

   3 infractions

   • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): The system to ensure that all policies and procedures are followed is ineffective. A review of Care plans identified admission checklists as incomplete. It was also identified that bathroom checklists were sporadically incomplete. Incomplete checklists may indicate that processes and checks were not completed as per policy. Submit by October 09, 2026, the plan that will be implemented to come into compliance with Section 85(1)(d) of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): The system to ensure that water accessible to persons in care is not heated to more than 49 degrees Celsius is ineffective. It was identified that there is no system to monitor or record the water temperature throughout the facility. Water temperatures exceeding 49 degrees Celsius presents risk for immersion burn. Submit by October 09, 2026, the plan that will be implemented to come into compliance with Section 17 of the Residential Care Regulation. The plan must also include a system for ongoing monitoring to ensure sustained compliance with the legislative requirements.
     • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
   • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): The system to ensure that records for each person in care who can leave the building independently is ineffective. A review of records did not adequately identify or address specific information such as any required assessments prior to leaving the facility, identifiers as to the whereabouts or locations of the intended leave. The absence of documented care planning for independent community access increases the risk that a person in care’s abilities, safety needs, and required supports are not adequately identified or addressed. Without clear planning and oversight, there is potential for unmet needs, increased risk of harm, and care delivery that does not align with assessed capabilities or licensing requirements. This was also a contravention on the previous inspection.
     • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
2. Routine InspectionSep 18, 2025

   4 infractions

   • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
     • Observation(s): The system to ensure that there are ongoing planned programs of physical, social and recreational activities is ineffective. The social / recreation calendar was noted on multiple days to not have any activities posted. The absence of a structured, ongoing program of physical, social, and recreational activities poses a risk to the mental, emotional, and physical well-being of persons in care. Submit by October 3, 2025, the plan that will be implemented to ensure ongoing compliance with Section 55(1)(a)(i) of the Residential Care Regulation.
     • R8.1A - Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55( 1 )(a)(i)
   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): The system to ensure that records for each person in care contain the required information is ineffective. During a review of the client identification sheets, it was noted that there was no picture of the person in care. The absence of identifiers such as a picture poses a potential safety risk to the person in care. Submit by October 3, 2025, the plan that will be implemented to ensure ongoing compliance with Section 78(1)(d) of the Residential Care Regulation.
     • R4.1I - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): The system to ensure that all rooms and common areas are maintained in a safe condition is ineffective. It was observed in a common area that a container of scissors used for crafts was not locked away. Unsupervised access to scissors poses a potential safety risk to persons in care. Submit by October 3, 2025, the plan that will be implemented to ensure ongoing compliance with Section 22(1)(c) of the Residential Care Regulation.
     • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
   • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): The system to ensure that records for each person in care who can leave the building independently is ineffective. Several client focused plans of care and client identification sheets did not contain details of the leaves or information on what steps to take if the person in care did not return by the expected time. Care plans for persons in care who can leave the facility independently must include specific details to support the safe outing and return to the facility. Submit by October 3, 2025, the plan which details what systems will be put in place to ensure all care plans for person in care who can leave the facility independently will be completed and updated as needed. The system to ensure care plans are updated is ineffective. A review of a care plan was noted to not have been reviewed or revised as indicated by the due date within the plan. Failure to update a care plan can result in care that does not reflect the person's current status or needs. Submit by October 3, 2025, the plan that will be implemented to ensure ongoing compliance with Section 81(4)(b)(i)(ii) of the Residential Care Regulation.
     • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
     • R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
3. Routine InspectionMar 19, 2025

   6 infractions

   • R7.2 - Is the environment maintained to prevent falls?
     • Observation(s): The system to ensure that all furniture and equipment used by persons in care is safe is ineffective. Currently there is no system to check electrical devices that family bring in such as TVs, computers, fans, heaters, digital clocks etc.
     • R7.2O - Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
   • R8.1 - Is there an ongoing planned program of physical, social and recreational activities?
     • Observation(s): The system to ensure ongoing planned program of physical, social and recreation activities is in effective. There were no social / recreation calendars identifying any planned program of activities within the facility.
     • R8.1A - Provide a program of activities, without charge, that is suitable to the needs of persons in care (Does not apply to Hospice); 55( 1 )(a)(i)
   • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): The system to ensure that all policies and procedures are followed is ineffective. A review of the Day / Bridge shift duties clipboard identified several checklists that were incomplete. Most notable was the client day shift checks and the knife draw checklist.
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): The system to ensure compliance with policy and procedures of the medication safety and advisory committee is ineffective. A review of the Medication Administrative Record's identified several PRN effectiveness not charted as per policy. This was also noted during the Pharmacist inspection on March 11th, 2025.
     • R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): The system for maintaining the physical environment in a good state of repair is ineffective as noted by two exit doors on the top floor missing the door trim. The system to ensure that all rooms and common areas are maintained in a safe condition is ineffective. A check on two shed doors containing gardening equipment were found to be unlocked. It was also observed that there were gardening tools left out in the garden area.
     • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
     • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
   • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): The system to ensure that care plans have all the components is ineffective. A random review of care plans identified no recreation and leisure plans.
     • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
4. Routine InspectionSep 26, 2024

   7 infractions

   • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
     • Observation(s): The system to ensure that the policy for medication errors contains all relevant information is ineffective. A review of the Medication policy (24.3.6) did not contain all the requirements of a reportable incident for medication errors as defined in Schedule D of the Residential Care Regulation.
     • R2.2D - Ensure there are written policies and procedures regarding monitoring of the medications of persons in care; 85( 2 )(h)
   • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): The system to ensure that all policies and procedures are followed is ineffective. A review of the daily monitoring checklist identified sporadically missed checks. It was also observed that the policy and procedure manual update / review was missing signatures. The system to ensure that all policies and procedures provide the steps to be taken by staff is ineffective. A review of the Absence without Official Leave (AWOL) policy (24.2.1) lacks clear comprehensive direction for steps to be taken by staff for person in care that are not on extended leave.
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
     • R2.1AA - Ensure there are written policies and procedures regarding steps to be taken if a person in care leaves, or may have left, the facility without notifying an employee; 85( 2 )(k)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): The system for Performance reviews is ineffective. Staff performance evaluations are currently overdue.
     • R3.1N - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): The system to ensure monthly weights are recorded is ineffective as it was observed during a chart review that several monthly weights were missed.
     • R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
   • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
     • Observation(s): The system to record fridge and freezer temperatures is ineffective. It was observed that temperatures were sporadically missed.
     • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
   • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
     • Observation(s): The system to ensure that monitoring the health and safety of each person in care regularly to determine if their needs continue to be met is ineffective. In reviewing a recently submitted Incident Report, it was identified that assessments had not taken place, and that a duty of care was not followed.
     • R10.2A - Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
   • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): The system to ensure that the care and supervision of persons in care is consistent with the terms of the care plan is ineffective. A review of a resident binder and the resident care plan binder identified a care plan for a person in care that had not been updated. This was corrected during the course of this inspection.
     • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
5. Routine InspectionMar 7, 2024

   8 infractions

   • R7.2 - Is the environment maintained to prevent falls?
     • Observation(s): The system to ensure that windows are secured to prevent falls or exit is ineffective. It was observed that windows in bedrooms could easily be opened to the full extent. The system to ensure laundry facilities have a slip resistant floor surface is ineffective. It was observed that there was no non-slip mat or flooring in place.
     • R7.2C - Windows must be secured to prevent falls from, or exiting through, the window; 15 ( 1 )
     • R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): The system to monitor the care and services is ineffective. Bathroom checklists were observed to be incomplete. No system in place to record or ensure daily checks are completed. Door alarms disengaged or not operational.
     • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
   • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): The system to ensure all policies are implemented is ineffective, a review of the first aid certification identified that a staff member not having valid first aid as per policy.
     • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
   • R4.6 - Are facility records current and complete?
     • Observation(s): The system to record menu substitutions is ineffective, there were no records.
     • R4.6C - Retain food services records of menus and menu substitutions; 87(b)
   • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
     • Observation(s): The system to ensure food is safely stored is ineffective, there were no temperature records maintained for the facility freezers.
     • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): The system to ensure all common areas are in a good state of repair is ineffective. It was observed that the pathway in the back of the facility is uneven posing a tripping and falls risk. This was a contravention on the last inspection. The cracks had been filled in but the pavement remains uneven. The system to ensure that bedrooms contain a secure place to store valuables is ineffective. It was observed that bedrooms did not contain a secure place in which a person in care may store valuable property.
     • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
     • R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 1 ) (a)
   • R9.1 - Are medications stored, handled, and administered appropriately?
     • Observation(s): The system to ensure that the facility only has medications that are prescribed is ineffective. It was observed that the facility had non-prescribed, over the counter medication.
     • R9.1E - Administer only medications prescribed or ordered by the medical or nurse practitioner; 70 ( 1 )
   • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): The system to ensure that Care plans have all the components is ineffective. A review of Care Plans identified that there were no Recreation plans. The system to ensure that a nutrition plan for each person in care is developed is ineffective. A review of Care plans identified that not all persons in care had a nutrition plan.
     • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
     • R10.3N - Develop a nutrition plan for each person in care and review the plan on a regular basis (Applies to a facility with 24 or fewer persons in care); 83( 1 )(a)( 3 )(a)
6. Routine InspectionMar 8, 2023

   3 infractions

   • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): There is no policy as requested by the Chief Medical Health Officers correspondence of June 2017 with respects to polices outlining the process employed by care staff to search baggage and the security measures that will be employed to monitor clients and visitors in the facility. This contravention was noted during the last routine inspection and was found unresolved during this visit. Policy and procedures observed to be dated 2015, while other policies were not dated.
     • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
     • R2.1Q - Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): Staff performance evaluations are currently overdue.
     • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): Cracks and uneven pavement on the pathway immediately outside the rear door which pose a tripping and falls risk.
     • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
7. Routine InspectionDec 9, 2019

   5 infractions

   • RB1.1 - Are all policies and procedures available to persons in care?
     • Observation(s): - There is no smoking policy and procedure. - There is no policy for a dispute resolution process. - There is no policy and procedure regarding; room checks and the checking of backpacks, as per MHO's June 30, 2017 letter.
   • RB1.5 - Are persons in care informed on how to express concerns or make complaints to the medical health officer or to the Patient Care Quality Office prior to admission?
     • Observation(s): There is no system in place to inform Person In Care, or their representatives, how to make a complaint to the Facility, or how to register a complaint with Licensing.
   • RB1.8 - Is there access to a fair, prompt and effective process to express concerns, make complaints or resolve disputes within the facility?
     • Observation(s): There is currently no formal process for Person In Care, or their representatives, to make complaints.
   • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): - There is no Policy and Procedure system in place to notify the Persons In Care, or their representative, on how to make a complaint to Licensing. - The facility does not have a dispute resolution process in place. - June 30, 2017 The Chief Medical Health Officer sent correspondence to 24th Ave, outlining that 'Licensing officers will review policies regarding the process employed by care staff to search baggage and the security measures that will be employed to monitor clients and visitors in the facility'. Policies are not in place to address the MHO's directives. - This is an outstanding contravention from the previous inspection report. There is no process to ensure that all employees were orientated to the Residential Care Regulations.
     • R2.1D - Prior to admission, advise how the person, their parent or representative may express concerns or make complaints to the Patient Care Quality Review Board Act; 48( 1 )(c)(ii)
     • R2.1J - Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(a)
     • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
     • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): - Facility does not have a smoking policy to guide staff on where and when they can use tobacco products. - It was noted that employees had been smoking on facility property, within the same locations as the Persons In Care.
     • R7.1M - Ensure that no one other than a person in care smokes while on the premises; 23(a)
     • R7.1N - Ensure that employees do not smoke while supervising persons in care; 23(b)
8. MonitoringApr 13, 2017

   6 infractions

   • RB1.17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
     • Observation(s): Please see report.
     • RB1.17A - Post the most recent routine inspection in a prominent place.
   • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): April 13, 2017 -The facility's system for ensuring that the manager's name is posted, and that the most recent inspection report is posted is ineffective as it was noted during inspection that this information was not posted in a prominent place. The posting of the most recent inspection report was corrected during inspection.
     • R1.1N - Prominently display in an acceptable manner, the licence, any terms or conditions, and the name of the manager. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(a), Act 7( 1 )(c)
     • R1.1O - Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
   • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): April 13, 2017 -The facility's system for ensuring that employees are orientated to the regulations and the Act are ineffective as two employees reported not being orientated to the regulations and the Act. The Team Leader reported that the fire-safety system check was about to be conducted. The facility holds a person in care and employee meeting at the end of each month and at this time the house rules are reviewed, the persons in care bring forward comments and concerns, and a fire drill is conducted.
     • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
   • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): April 13, 2017 -The facility's system for ensuring that the performance of each employee is reviewed regularly is ineffective as the Team Leader reported that performance evaluations are not up to date. The balance of requirements for employee files is kept at the head office. The Team Leader keeps an employee file spread sheet. This was reviewed and appeared to be complete.
     • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
   • R4.6 - Are facility records current and complete?
     • Observation(s): April 13, 2017 -The facility's system for ensuring that there is a record of the most recent medication safety and advisory committee meeting is ineffective as the most recent record could not be located at the time of inspection. The Team Leader had the pharmacy fax the minutes to the facility during the inspection. The minutes were reviewed and a system for disseminating the information to the employees was discussed.
     • R4.6A - Keep a copy of each policy and procedure of the medication safety and advisory committee; 85 ( 3 )
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): April 13, 2017 -The facility's system for ensuring that the water accessible to persons in care does does not exceed 49 degrees Celsius in temperature is ineffective as it was noted that the water temperature in several locations measured from 51.3 to 56.0 degrees Celsius. The facility immediately posted signs cautioning the persons in care to the high water temperatures, and confirmed that maintenance would be on location on April 18, 2017 to regulate the temperatures. The Team Leader reported that a system is in place for monitoring the physical condition of the premises. It was noted that a system is in place to provide privacy screens in double rooms for the persons in care who wish to use them.
     • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
9. MonitoringJun 16, 2015

   6 infractions

   • 25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
     • Observation(s): As previously noted in inspection report.
     • Ensure care plans are developed within 30 days.
   • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
     • Observation(s): The facility has baseboard heat and electricity as their only utility source. The facility does not have an emergency preparedness plan in regards to a power outage. There is no evidence on record to show that policies and procedures are reviewed at least once a year. Unable to locate policy on record keeping.
     • Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
     • Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
     • Ensure there are written policies and procedures regarding the appropriate manner and schedule of record keeping; 85( 2 )(l)
   • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): Staffing spread sheet was incomplete in the areas as follows: Criminal record checks for all staff were to be completed on the Ministry form in 2011/2012. Several old criminal record checks were dated 1998, 1999 and 2008. All staff are to have the Ministry form completed and these criminal record checks are to be conducted every 5 years following. Several staff records revealed that only one character reference was completed. Two or more reference checks are required to meet the Regulation. The staffing spread sheet revealed that several staff did not have any copies of diplomas, certificates or evidence of training or skills. The staffing spread sheet revealed that several staff did not have immunization or tuberculosis screening completed. Evidence of TB test results are mandatory records for all staff. The staffing spread sheet revealed that several employees did not have performance evaluations completed. Policy indicates yearly performance evaluations. The staffing spread sheet revealed several expired first aid/CPR certification.
     • Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
     • Obtain character references for all employed persons; 37( 1 )(b)
     • Obtain copies of diplomas, certificates or other evidence of training and skills for all employed persons; 37( 1 )(d)
     • Obtain evidence that employed persons comply with the province's immunization and tuberculosis control programs; 37( 1 )(e)
     • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
     • Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
   • 4.1 Are person in care records current, complete and kept confidential?
     • Observation(s): There are not written consents in the person in care records to call a medical or nurse practitioner or ambulance in case of accident or illness.
     • Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
   • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): Privacy screening is not available and this item remains outstanding from the past inspection. The manager stated that the proper screening device is difficult to obtain as the device must be safe for all persons in care and appropriate for bedroom. There are ceiling fans in the bedrooms, device must be sturdy enough to support weight if a person in care reaches out to steady oneself. Bedrooms are quite small and device can only require a small amount of space. Screening options are still being pursued but thus far the options available have not been appropriate.
     • Ensure that double occupancy bedrooms are screened for privacy and dignity; 25 ( 2 ) (b)
   • 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
     • Observation(s): There are no nutritional care plans on record for those persons in care staying at the facility for over 30 days.
     • Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)