Aberdeen House

Confidential · Residential Care - Licensing

9 inspections

1. Routine InspectionJun 9, 2026

   1 infraction

   • R7.2 - Is the environment maintained to prevent falls?
     • Observation(s): The laundry facilities do not have a slip resistant floor surface. A non-slip mat was suggested as an option to correct this. This could pose a slipping and fall hazard and could jeopardize the health and safety of person in care. Submit by June 25, 2026, evidence that a plan has been implemented to ensure that the laundry facilities do not pose a slip or fall hazard.
     • R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(a)
2. Routine InspectionJun 10, 2025

   2 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 emergency plan lacked details about transportation logistics as well as the alternate locations should the facility be evacuated. The manager confirmed that staff were not familiar with the plan and had not been trained in its implementation. This is a repeat contravention. The lack of a complete and comprehensive emergency plan, as well as staff knowledge regarding its implementation poses a risk to the health and safety of persons in care should an emergency occur.
     • R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): The following deficiencies were noted the exterior of the physical facility; chipped and worn paint around window frames, cracks and holes in the plastic siding flashing and a worn wooden cover placed on a portion of the patio. These issues could potentially impact the health safety and dignity of persons in care if not addressed. A regular maintenance routine is required to ensure the physical facility is kept in a safe and clean condition.
     • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
3. Routine InspectionApr 16, 2024

   1 infraction

   • 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): Emergency plan was not complete or displayed in a prominent place.
     • R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
     • R2.1I - Display a copy of the emergency plan in a prominent place; 51 ( 4 )
4. Routine InspectionMay 2, 2023

   3 infractions

   • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
     • Observation(s): PRN effectiveness is not being regularly charted on the MAR.
     • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
   • R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
     • Observation(s): One PIC chart lacked a completed TB screening form.
     • R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): Some fluorescent lights in common corridors are missing covers, leaving lighting fixture exposed.
     • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
5. Routine InspectionApr 12, 2022

   4 infractions

   • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
     • Observation(s): Medication administration records were reviewed during this inspection, the effectiveness of or PRN medication was observed as not charted several times over the past month.
     • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
   • R4.1 - Are person in care records current, complete and kept confidential?
     • Observation(s): Two care plans for newer admissions who have been at the site for more than 30 days did not include all required elements of RCR 81 Care Plans.
     • R4.1Q - Ensure a care plan is developed within 30 days for persons in care admitted for more than 30 days; 81.1; Director of Licensing Standards of Practice: Advance Directives and Care Plans
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): Bedrooms include side tables which have lockable drawers, however some of the locks were observed as broken during this inspection.
     • R7.1Y - Provide bedroom furnishings including a safe, secure place to store valuable property at no cost to persons in care; 29( 1 ) (a)
   • 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): Recreation care plans were reviewed/discussed during this inspection, the plans did not always give specific information regarding the recreation interests/needs of each PIC within the home and during potential outings away from the home. Ensure recreation plans give specific information for each PIC, and facility charting includes information detailing recreation completed.
     • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
6. MonitoringApr 9, 2018

   4 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 facility does not have a process in place to ensure policies and procedures are reviewed at least once a year.
     • 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): The facility does not have a process in place to ensure all employees hold valid first aid certificates. It was noted during the inspection first aid certificates had expired for several staff members this past month. Staff members do take persons in care off site at times, so first aid is required for all staff members.
     • R3.1O - 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)
   • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
     • Observation(s): The menu plan was reviewed and it was noted the weekly menu plan did not always include two food groups per snack.
     • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
   • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): It was noted during the inspection the caulking in one of the showers was pulling away from the seams and is in need of repairs.
     • R7.1I - Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
7. MonitoringApr 12, 2016

   4 infractions

   • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
     • Observation(s): April 12, 2016 OUTSTANDING INFRACTION -It was noted that the facility had begun to conduct immunization screening for the persons in care, however the majority of persons in care still require immunization screening, information, and documentation. The manager reported that a plan is in place to have this completed by April 30, 2016.
     • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
     • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
     • Provide information to persons in care regarding the benefits of immunization including pneumococcal, annual influenza and tetanus-diphtheria if appropriate; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
   • 8 - Is there access to a fair, prompt and effective process to express concerns, make complaints or resolve disputes within the facility?
     • Observation(s): -It was noted that the facility complaints process was incomplete as complaint forms were not readily available to persons in care, the complaints process had not been reviewed at a resident/family meeting since March 2012, and the record of complaints contained one complaint with no documentation of facility investigation with staff.
   • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): April 12, 2016 NEW INFRACTION -It was noted that a copy of the most recent inspection report was not posted - This was corrected during inspection. OUTSTANDING INFRACTION -It was noted that documentation could not be provided for the offering of influenza immunization to the persons in care, benefits of immunization, or if the persons in care refused the immunization. This process was stated to be in place in the facilities' Compliance Plan, however the facility monitoring system did not identify that this had not occurred. The facilities' Compliance Plan was effective in the monitoring of compliance with all other infractions from the previous inspection.
     • 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)
     • Regularly monitor the physical environment and the care and services provided; 61
   • 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): April 12, 2016 NEW INFRACTION -It was noted that the facility complaints process was incomplete as complaint forms were not readily available to persons in care, the complaints process had not been reviewed at a resident/family meeting since March 2012, and the record of complaints contained one complaint with no documentation of facility investigation with staff.
     • Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(a)
8. MonitoringOct 29, 2015

   11 infractions

   • 4.5 Are incidents and notifications reported and records retained as required?
     • Observation(s): Incident reports have been submitted late 75% the past year. Late submission is noted to be on the increase.
     • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
   • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
     • Observation(s): The spread sheet provided for the Licensing Officer to review was incomplete on several staff member for compliance with immunization and tuberculosis control programs. This remains outstanding from the past inspection report.
     • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
   • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
     • Observation(s): Unable to locate immunization screening documentation for persons in care. This remains outstanding from the past inspection report.
     • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
   • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
     • Observation(s): Several outstanding infractions remain on the inspection report and recurring infractions noted that were reported as followed up and resolved have also been noted. A discussion took place with the manager in regards to self monitoring and devising a self monitoring tool or checklist to assist in meeting the Regulation.
     • Regularly monitor the physical environment and the care and services provided; 61
   • 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 emergency preparedness manual and policies were noted to be incomplete on several emergencies such as power outage, flood and gas leak. What was on site was vague and did not address specifics in responding to and recovering from. The facility emergency contact call out sheet has not been updated with the manager change. The Licensing Officer and manager were unable to locate the policy on adverse reactions to medications. Communication had been sent indicating that this infraction had been resolved. This is a recurring infraction. Several policies in the facility policy binders have been written on and X'd off without any follow up. There is no evidence that the majority of the policies have been reviewed yearly. Monthly fire safety and equipment checks/tests checklists have not been completed since July of 2015.
     • Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
     • Update emergency plans if there is any change in the facility; 51 ( 2 )
     • Establish and review policies and procedures for the immediate response to and reporting of medication errors and adverse reactions to medications; 68( 3 )(b)(ii)
     • Review and, if necessary, revise policies and procedures at least once a year; 85( 1 )(b)
     • Ensure policies are implemented by employees; 85( 1 )(d)
   • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): The staffing spread sheet provided by the manager for the Licensing Officer to review did not have an area for reference checks, work history or copies of diplomas or certificates on it. This remains outstanding from the past inspection report. TB screening and immunization screening was not marked or dated on several staff on the spread sheet provided. This remains outstanding from the past inspection report. Performance evaluations have not been completed on several staff. This remains outstanding from the past inspection report. Several staff were noted to have incomplete First aid and CPR certification. Only 6 staff are noted to have current first aid and CPR. The manager stated that all of the remainder of the staff who do not have current first aid have been scheduled to take the course on Nov. 21 and 22, 2015. This remains outstanding from the past inspection report. There has only been one fire drill completed this past year and the drill was just completed in Oct. 2015. Fire drills have not been completed as per the facility policy. This remains outstanding from the past two inspection reports.
     • Obtain character references for all employed persons; 37( 1 )(b)
     • Obtain a record of work history for all employed persons; 37( 1 )(c)
     • 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)
     • Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
   • 4.1 Are person in care records current, complete and kept confidential?
     • Observation(s): Unable to locate any written consents to call the medical or nurse practitioner or ambulance. The manager was not able to locate consents either.
     • 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)
   • 4.4 Are records kept on each employee with the necessary requirements?
     • Observation(s): Spread sheet information did not include character references. This remains outstanding from the past inspection report. Spread sheet information was incomplete for several staff in regards to TB and immunization screening. This remains outstanding from the past inspection report.
     • Keep employee character references; 86(b)
     • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
   • 4.6 Are facility records current and complete?
     • Observation(s): It was noted that the weekly menu written on the menu board in the kitchen did not coincide with the weekly menu plan posted on the fridge in the kitchen. There have been no menu substitutions noted on the menu substitution log for several months.
     • Retain food services records of menus and menu substitutions; 87(b)
   • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
     • Observation(s): Three food groups for meals was not always provided on the four week menu plan.
     • Provide for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups described in Canada's Food Guide; 62( 2 )(a)
   • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): Water temperature taken today measured at 58 degrees Celsius. Communication had been sent indicating that this infraction had been resolved. This is a recurring infraction and immediate follow up was discussed with the manager. Damage to hallway walls noted throughout the facility. Damage noted to the wall in a person in care room. This remains outstanding from the past inspection.
     • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
     • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
9. MonitoringFeb 10, 2015

   12 infractions

   • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
     • Observation(s): Several missed signatures for regularly scheduled medications noted on the Medication Administration Record.
     • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78(2)(b)
   • 6.1 Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
     • Observation(s): TB screening noted to be missing from several staff records reviewed on site today.
     • Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 (1)
   • 6.2 Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
     • Observation(s): There are no up to date records of immunization status for persons in care being admitted to facility. TB screening is being completed.
     • Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 (1)
     • Keep clear and up to date records of the immunization status of each person in care; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
     • Provide information to persons in care regarding the benefits of immunization including pneumococcal, annual influenza and tetanus-diphtheria if appropriate; Director of Licensing Standards of Practice: Immunization of Adult Persons in Residential Care
   • 7.2 Is the environment maintained to prevent falls?
     • Observation(s): Soiled chair noted in the lounge area.
     • Furniture and equipment for use by persons in care must be maintained in a safe and clean condition; 21(d)
   • 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): Facility does not have a policy in regards to responding to and reporting of adverse reactions to medications.
     • Establish and review policies and procedures for the immediate response to and reporting of medication errors and adverse reactions to medications; 68(3)(b)(ii)
   • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
     • Observation(s): Criminal record checks are not included in the staff records. It was not known which criminal record checks were being completed as the RCMP criminal record checks are not an acceptable check for Licensing. Reference checks noted to be missing from a sampling of staff files reviewed. Work history noted to be missing from a sampling of staff files reviewed. Copies of certificates and diploma noted to be missing from a sampling of staff files reviewed. TB screening noted to be missing from a sampling of staff files reviewed. Performance evaluations noted to be missing from some of the sampling of staff files reviewed and in discussion with the manager, some staff evaluations are overdue. Expired or missing first aid certificates noted to be missing from some of the sampling of staff records reviewed as well as the staffing template provided by the facility. Fire drills were not being completed on a regular basis as described in the fire manual. Several staff members were identified as not having participated in the fire drills offered on site. This remains outstanding from previous inspection report.
     • Ensure criminal record checks are obtained for all employed persons; 37(1)(a)
     • Obtain character references for all employed persons; 37(1)(b)
     • Obtain a record of work history for all employed persons; 37(1)(c)
     • 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)
     • Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 (3)
   • 4.4 Are records kept on each employee with the necessary requirements?
     • Observation(s): As per noted above - criminal record checks were not available in the staff records and it was unknown which criminal record check was being completed. Reference checks missing from the staff documentation available on site. TB screens missing from several staff records available on site as well as from the staff template provided on site. Performance review on a staff member who has worked at the facility for several years has not been completed.
     • Keep employee criminal record check results; 86(a)
     • Keep employee character references; 86(b)
     • Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
     • Keep a record of any employee performance reviews and any attendance at continuing education programs; 86(d)
   • 5.1 Does the facility provide food services which meet nutritional needs and preferences for persons in care?
     • Observation(s): Menu plan did not have at least two nutritious snacks with at least two food groups described in the Canada Food Guide.
     • Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62(2)( c)(i)
   • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
     • Observation(s): There is a small bar fridge in one of the lounges being used to store food. Temperature checks and temperature logs are not being completed on this fridge.
     • Ensure that food is safely prepared, stored, served and handled; 63 (1)
   • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
     • Observation(s): Water temperature measured at 52 degrees Celsius. This infraction requires immediate attention and follow up. Wall damage noted in the lounge area as well as the hallways. Damage noted to the door in one of the bathrooms as well as one of the bedrooms. Sprinkler system has not been professionally checked since 2012. It was previously noted that yearly checks were being completed.
     • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
     • Maintain all rooms and common areas in a good state of repair; 22(1)(b)
     • Inspect and maintain on a regular basis all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices; 22 (3)
   • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
     • Observation(s): Identification is not meeting the standard of the Regulation. Name of the facility is not written on the identification label.
     • Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56(1) (18)
   • 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): It was noted that oral and nutritional care plans in a sampling of person in care records have not been reviewed for over 1 year.
     • 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)