Consort Hospital and Care Centre

1. March 12, 2026 · CCHSS Inspection

   Non-compliant

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

     Issued March 12, 2026. Fix by June 4, 2026. Status: Rectified (March 12, 2026).

   • Staff Training — Documented compliance to training.

     An operator must document compliance with the requirements in 9.1, 9.2, and 9.3.

     Issued March 12, 2026. Fix by July 15, 2026. Status: Issued (March 12, 2026).

   • Restraint Management and Secure Spaces — Documentation for restraint use.

     Issued March 12, 2026. Fix by June 4, 2026. Status: Rectified (March 12, 2026).

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

     Issued March 12, 2026. Fix by June 4, 2026. Status: Rectified (March 12, 2026).

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

     Issued March 12, 2026. Fix by June 4, 2026. Status: Rectified (March 12, 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 March 12, 2026. Fix by June 4, 2026. Status: Rectified (March 12, 2026).

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

     Issued March 12, 2026. Fix by June 4, 2026. Status: Rectified (March 12, 2026).

   • Assistive Equipment, Technology And Medical/Surgical Supplies — Policies and procedures on maintaining equipment owned by Operator and reporting if unsafe.

     Issued March 12, 2026. Fix by June 4, 2026. Status: Rectified (March 12, 2026).

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

     Issued March 12, 2026. Fix by June 4, 2026. Status: Rectified (March 12, 2026).

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

     Issued March 12, 2026. Fix by June 4, 2026. Status: Rectified (March 12, 2026).

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

     Issued March 12, 2026. Fix by June 4, 2026. Status: Rectified (March 12, 2026).

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

     Issued March 12, 2026. Fix by June 4, 2026. Status: Rectified (March 12, 2026).

2. December 1, 2025 · Inspection

   Non-compliant

   • Water Temperature — Training, maintenance, and risk mitigation to ensure safe water temperatures

     Evidence required that regularly scheduled checks are in place to ensure that safe water temperature

     Issued December 1, 2025. Fix by February 11, 2026. Status: Rectified (December 1, 2025).

   • Trust Accounts — Written policy for trust accounts

     Evidence required of a maintained, implemented and written policy for trust accounts and the written

     Issued December 1, 2025. Fix by February 11, 2026. Status: Rectified (December 1, 2025).

   • Menu Requirements — Resident consultation on meal times

     Evidence required that residents are consulted, every 6 months at minimum, regarding meal times and

     Issued December 1, 2025. Fix by February 11, 2026. Status: Rectified (December 1, 2025).

   • Concerns and Complaints — Written processes for managing concerns and complaints

     Evidence required of communication of the written process to residents, their representatives, visit

     Issued December 1, 2025. Fix by February 11, 2026. Status: Rectified (December 1, 2025).

3. November 2, 2023 · CCHSS Audit

   Non-compliant

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

     Issued November 2, 2023. Fix by January 30, 2024. Status: Rectified (February 10, 2024).

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

     Issued November 2, 2023. Fix by January 30, 2024. Status: Rectified (March 7, 2024).

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

     Issued November 2, 2023. Fix by January 30, 2024. Status: Rectified (March 7, 2024).

   • Restraint Management — Documentation for restraint use.

     Issued November 2, 2023. Fix by January 30, 2024. Status: Rectified (April 26, 2024).

   • Nutrition and Hydration Management — Nutrition and hydration interventions reviewed and documented in Care Plan.

     An operator must ensure that the directions for nutrition and hydration interventions for a Client a

     Issued November 2, 2023. Fix by January 30, 2024. Status: Rectified (April 26, 2024).

   • 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 November 2, 2023. Fix by January 30, 2024. Status: Rectified (February 10, 2024).

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

     Issued November 2, 2023. Fix by January 30, 2024. Status: Rectified (March 7, 2024).

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

     Issued November 2, 2023. Fix by January 30, 2024. Status: Rectified (February 10, 2024).

   • Quality Improvement and Reporting — Policies and procedures for reportable incidents are documented and implemented.

     An operator must establish, implement and maintain documented policies and procedures for the preven

     Issued November 2, 2023. Fix by January 30, 2024. Status: Rectified (February 10, 2024).

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

     Issued November 2, 2023. Fix by January 30, 2024. Status: Rectified (March 7, 2024).

4. December 13, 2022 · 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 December 13, 2022. Fix by January 3, 2023. Status: Rectified (January 13, 2023).

   • Continuation of Services — Contingency plans

     Evidence required that the continuation of services plan includes provisions for loss of utilities,

     Issued December 13, 2022. Fix by January 3, 2023. Status: Rectified (January 9, 2023).

5. March 2, 2022 · Quality Monitoring Visit

   Compliant

6. January 20, 2022 · Quality Monitoring Visit

   Non-compliant

   • standard not recorded in the file

     Issued January 20, 2022. Status: Resolved (March 2, 2022).

7. February 3, 2021 · Quality Monitoring Visit

   Compliant

8. January 19, 2021 · CMOH Inspection

   Non-compliant

   • COVID-19 Chief Medical Officer of Health Orders Expectations Not Met — Visitation

     Issued January 19, 2021. Fix by January 21, 2021. Status: Rectified (January 22, 2021).

   • COVID-19 Chief Medical Officer of Health Orders Expectations Not Met — Entry Screening Process

     Issued January 19, 2021. Fix by January 21, 2021. Status: Rectified (January 22, 2021).

9. January 14, 2021 · Quality Monitoring Visit

   Non-compliant

   • standard not recorded in the file

     Issued January 14, 2021. Status: Resolved (February 3, 2021).

   • standard not recorded in the file

     Issued January 14, 2021. Status: Resolved (February 3, 2021).

   • standard not recorded in the file

     Issued January 14, 2021. Status: Resolved (February 3, 2021).

   • standard not recorded in the file

     Issued January 14, 2021. Status: Resolved (February 3, 2021).

10. September 8, 2020 · Quality Monitoring Visit

    Compliant

11. August 10, 2020 · Quality Monitoring Visit

    Non-compliant

    • standard not recorded in the file

      Issued August 10, 2020. Status: Resolved (September 8, 2020).

12. April 6, 2020 · Consultation

    Not assessed (consultation)

13. August 20, 2019 · Inspection

    Non-compliant

    • Duties of an Operator — Establish a Written Process for Addressing Concerns

      Provide evidence that a written process is established for addressing requests and_x000D_ concerns of th

      Issued August 20, 2019. Fix by November 30, 2019. Status: Rectified (October 21, 2019).

14. August 20, 2019 · Inspection

    Non-compliant

    • Menu Requirements — Menu substitutions communicated and made from same food group

      Evidence required of the menu substitutions showing that the substitutions are from within the same

      Issued August 20, 2019. Fix by November 30, 2019. Status: Rectified (November 4, 2019).

15. July 16, 2019 · CCHSS Audit

    Non-compliant

    • CCHSS standard 1.2

      The care plan reflects the findings of the assessment and is kept up to date.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

    • CCHSS standard 1.3

      The care plan addresses the Client's needs, goals, and intervention details.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

    • CCHSS standard 1.4

      Medical Status assessments are documented.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

    • CCHSS standard 1.8

      Client's Care Plan is reviewed.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

    • CCHSS standard 4.4

      Personal Directives, Power of Attorney, guardian/trusteeship or Advance Care Planning information.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

    • CCHSS standard 10.1

      Managed risk agreements are documented and implemented.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

    • CCHSS standard 12.1

      Policies and procedures in Medication Management are documented and implemented.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

    • CCHSS standard 15.1

      Policies and procedures regarding safe water temperatures are documented and implemented.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

    • CCHSS standard 16.1

      Policies and procedures regarding Restraint use are documented and implemented.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

    • CCHSS standard 16.3

      Documentation for restraint use.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

    • CCHSS standard 16.4

      Policies and procedures for Secure Spaces are documented and implemented.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

    • CCHSS standard 16.5

      Secure Space usage is documented and reviewed by the Interdisciplinary Team.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

    • CCHSS standard 16.6

      Secure Space usage is documented in Client's chart and Care Plan.

      Issued July 16, 2019. Status: Resolved (July 13, 2020).

16. August 15, 2018 · Inspection

    Compliant

17. August 15, 2018 · Inspection

    Non-compliant

    • Prevention of Abuse — Information provision on preventing and reporting abuse

      Evidence required that information regarding the identification and reporting of suspected abuse and

      Issued August 15, 2018. Fix by November 30, 2018. Status: Rectified (October 22, 2018).

    • Water Temperature — Therapeutic tub temperature checks

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

      Issued August 15, 2018. Fix by September 30, 2018. Status: Rectified (September 21, 2018).

    • Residents Personal Affairs — Communication of processes

      Evidence required that the policies on involvement in residents' personal affairs have been communic

      Issued August 15, 2018. Fix by November 30, 2018. Status: Rectified (November 13, 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 August 15, 2018. Fix by November 30, 2018. Status: Rectified (November 13, 2018).

    • Residents Personal Affairs — Requirements for written processes

      Evidence required of written policies that address the accepting of gifts and the involvement of emp

      Issued August 15, 2018. Fix by September 30, 2018. Status: Rectified (September 21, 2018).

18. August 8, 2017 · Inspection

    Compliant

19. August 10, 2016 · Inspection

    Non-compliant

    • Menu Requirements — Menu substitutions communicated and made from same food group

      Evidence required of the menu substitutions showing that the substitutions are from within the same

      Issued August 10, 2016. Fix by September 30, 2016. Status: Rectified (September 22, 2016).

    • Nutritional Requirements — Quality and quantity of food, communication of menu/times

      Evidence required that residents are aware of the times that meals, fluids and snacks are served, an

      Issued August 10, 2016. Fix by September 30, 2016. Status: Rectified (September 22, 2016).

    • Resident Safety and Security — Incident reporting

      Please submit completed reportable incident form for the incident on DATE within one business day.

      Issued August 10, 2016. Fix by September 30, 2016. Status: Rectified (August 16, 2016).

20. July 28, 2015 · Inspection

    Compliant

21. August 20, 2014 · 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 August 20, 2014. Fix by December 31, 2014. Status: Rectified (November 24, 2014).

22. October 22, 2013 · CCHSS Regular Audit

    Non-compliant

    • Communicable Disease and Infection Prevention and Control — Services are provided in accordance with all communicable disease, & IPC standards issued by AH .

      (a) Continuing care health services shall be provided in accordance with all communicable disease an

      Issued October 22, 2013. Fix by January 31, 2014. Status: Rectified (June 23, 2014).

    • Medication Management — Medication management policies and processes in place and implemented.

      (a) Medication management policies and processes are in place and implemented.

      Issued October 22, 2013. Fix by January 31, 2014. Status: Rectified (June 23, 2014).

23. August 13, 2013 · 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 August 13, 2013. Fix by October 31, 2013. Status: Rectified (October 15, 2013).

• How does the home meet: Restraint Management and Secure Spaces — Policies and procedures regarding Restraint use are documented and implemented.?
• How does the home meet: Staff Training — Documented compliance to training.?
• How does the home meet: Restraint Management and Secure Spaces — Documentation for restraint use.?
• How does the home meet: Infection Prevention and Control — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.?
• How does the home meet: Medication Management — Policies and procedures in Medication Management are documented and implemented.?
• How does the home meet: Standardized Assessment and Person-Centred Care Planning — An appropriate assessment tool for Client's Health Care needs is used.?

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