Central Peace Health Complex

1. April 29, 2026 · CCHSS Inspection

   Non-compliant

   • Palliative Care and End-of-Life Care — Palliative Care and End-of-Life care documentation in Care Plan.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Standardized Assessment and Person-Centred Care Planning — Medical Status assessments are documented.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Restraint Management and Secure Spaces — Secure Space usage is documented in Client's chart and Care Plan.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Staff Training — Policies and procedures for Staff training are documented and implemented.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 28, 2026).

   • Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Oral Care Assistance and Bathing Frequency in Continuing Care Homes — Documented bathing preference in Care Plan.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Standardized Assessment and Person-Centred Care Planning — An appropriate assessment tool for Client's Health Care needs is used.

     An operator must ensure that a client's health care needs are assessed using the appropriate InterRA

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Risk Management — Clients understand their choice to live at risk.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Client Access to Information — Information is provided about Health Care, services and responsibilities.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Medication Management — Policies and procedures in Medication Management are documented and implemented.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Continuity of Health Care — Documented emergency preparedness, pandemic and contingency plan.

     An operator must establish, implement, and maintain documented emergency preparedness, pandemic, and

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Infection Prevention and Control — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Standardized Assessment and Person-Centred Care Planning — The care plan reflects the findings of the assessment and is kept up to date.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Oral Care Assistance and Bathing Frequency in Continuing Care Homes — Policies and procedures to provide Clients the opportunity for assistance with oral care.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Life Enrichment Services — Life Enrichment Services are provided as per Client's Care Plan.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Safe Bath and Shower Water Temperature — Policies and procedures for water supply system and temperature checks

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Continuity of Health Care — Emergency preparedness, pandemic, contingency plans mitigate risks, are reviewed and communicated.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Staff Training — Policies and procedures for Staff training are documented and implemented.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

   • Concerns Resolution on Health Care — Policy and procedure for responding to concerns about the Health Care provided.

     Issued April 29, 2026. Fix by July 28, 2026. Status: Issued (April 29, 2026).

2. October 18, 2022 · Inspection

   Compliant

3. April 1, 2020 · Consultation

   Not assessed (consultation)

4. February 5, 2020 · Inspection

   Non-compliant

   • Duties of an Operator — Provide Inspection Results

     Provide evidence that information on inspection results have been provided to_x000D_ residents and their

     Issued February 5, 2020. Fix by February 29, 2020. Status: Rectified (February 10, 2020).

5. February 5, 2020 · Inspection

   Non-compliant

   • Information Respecting the Long Term Care Accommodation — Signed residential services agreement

     Evidence required that residential service agreements have been signed by the resident/representativ

     Issued February 5, 2020. Fix by February 29, 2020. Status: Rectified (February 10, 2020).

6. July 17, 2019 · CCHSS Audit

   Non-compliant

   • Assistive Equipment, Technology And Medical/Surgical Supplies — Policies and procedures on reporting unsafe equipment not owned by Operator.

     Where an operator uses assistive equipment that it does not own for the purpose of providing health

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (July 3, 2020).

   • Infection Prevention and Control (IPC) — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (February 13, 2020).

   • Medication Management — Policies and procedures in Medication Management are documented and implemented.

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (February 13, 2020).

   • Oral Care Assistance and Bathing Frequency — Policies and procedures to provide Clients the opportunity for assistance with oral care.

     The policies and procedures in 14.1(a) must provide the client with the opportunity for assistance w

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (February 13, 2020).

   • Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (February 13, 2020).

   • Restraint Management — Documentation for restraint use.

     Issued July 17, 2019. Fix by February 2, 2024. Status: Rectified (February 5, 2024).

   • Restraint Management — Policies and procedures for Secure Spaces are documented and implemented.

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (July 3, 2020).

   • Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.

     Issued July 17, 2019. Fix by February 2, 2024. Status: Rectified (February 5, 2024).

   • Restraint Management — Restraint use is reviewed by the Interdisciplinary Team.

     Operator must ensure that when a restraint is used, it is reviewed by the Interdisciplinary Team on

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (July 3, 2020).

   • Restraint Management — Secure Space usage is documented and reviewed by the Interdisciplinary Team.

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (July 3, 2020).

   • Restraint Management — Secure Space usage is documented in Client's chart and Care Plan.

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (July 3, 2020).

   • Risk Management — Managed risk agreements are documented and implemented.

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (November 3, 2022).

   • Staff Training — Policies and procedures for Staff training are documented and implemented.

     Issued July 17, 2019. Fix by February 2, 2024. Status: Rectified (February 4, 2024).

   • Standardized Assessment and Person-Centred Care Planning — Changes in Care Plans are documented and communicated.

     An operator must ensure that any change to a client's care plan is documented and communicated to th

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (February 13, 2020).

   • Standardized Assessment and Person-Centred Care Planning — Client and/or Client's legal representative participate in the development and review of Care Plan.

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (February 13, 2020).

   • Standardized Assessment and Person-Centred Care Planning — Client's or representative's lack of participation in the Care Plan is documented.

     Where a client or the client's legal representative, if applicable, is unable or unwilling to partic

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (July 3, 2020).

   • Standardized Assessment and Person-Centred Care Planning — Medical Status assessments are documented.

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (July 3, 2020).

   • Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.

     Issued July 17, 2019. Fix by October 21, 2019. Status: Rectified (February 13, 2020).

7. January 30, 2019 · Inspection

   Compliant

8. January 30, 2019 · Inspection

   Non-compliant

   • Maintenance Requirements — Preventative and corrective maintenance

     Evidence required of a scheduled preventative maintenance and repair program.

     Issued January 30, 2019. Fix by May 31, 2019. Status: Rectified (May 3, 2019).

   • Continuation of Services — Practicability, communication, and review of plans

     Evidence required that the continuation of services plan is practical, identifies relevant supports,

     Issued January 30, 2019. Fix by April 30, 2019. Status: Rectified (March 25, 2019).

9. May 17, 2018 · Inspection

   Compliant

10. February 8, 2018 · Inspection

    Non-compliant

    • Water Temperature — Safe water temperatures

      Evidence required that the hottest water temperature flowing out of the faucets in resident areas do

      Issued February 8, 2018. Fix by April 30, 2018. Status: Rectified (March 22, 2018).

    • Resident Safety and Security — Training on security, communication, and emergency call systems

      Evidence required that training for the security, communication, or emergency call systems has been

      Issued February 8, 2018. Fix by March 31, 2018. Status: Rectified (March 20, 2018).

    • Cleaning Requirements — Regularly scheduled cleaning of all areas

      Evidence required that the accommodation is cleaned on a regularly scheduled basis.

      Issued February 8, 2018. Fix by March 31, 2018. Status: Rectified (February 12, 2018).

11. February 16, 2017 · Inspection

    Compliant

12. February 18, 2016 · Inspection

    Non-compliant

    • Water Temperature — Therapeutic tub temperature checks

      Evidence required of the testing of the temperature of the hottest flowing water from each therapeut

      Issued February 18, 2016. Fix by June 30, 2016. Status: Rectified (May 20, 2016).

    • Water Temperature — Safe water temperatures

      Evidence required that the hottest water temperature flowing out of the faucets in resident areas do

      Issued February 18, 2016. Fix by October 31, 2016. Status: Rectified (October 3, 2016).

13. February 13, 2015 · Inspection

    Non-compliant

    • Criminal Record Checks — Completion of criminal record checks

      <p>Evidence required that each employee, volunteer and service provider who provide services directl

      Issued February 13, 2015. Fix by March 31, 2015. Status: Rectified (March 5, 2015).

14. February 19, 2014 · Inspection

    Non-compliant

    • Continuation of Services — Practicability, communication, and review of plans

      Evidence required that the continuation of services plan is practical, identifies relevant supports,

      Issued February 19, 2014. Fix by May 31, 2014. Status: Rectified (April 23, 2014).

• How does the home meet: Palliative Care and End-of-Life Care — Palliative Care and End-of-Life care documentation in Care Plan.?
• How does the home meet: Standardized Assessment and Person-Centred Care Planning — Medical Status assessments are documented.?
• How does the home meet: Restraint Management and Secure Spaces — Secure Space usage is documented in Client's chart and Care Plan.?
• How does the home meet: Staff Training — Policies and procedures for Staff training are documented and implemented.?
• How does the home meet: Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.?
• How does the home meet: Oral Care Assistance and Bathing Frequency in Continuing Care Homes — Documented bathing preference in Care Plan.?

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