Type B (designated supportive living)
Villa Marie
Red Deer, Alberta. Operated by Covenant Care.
- Visits since 2023
- 14
- 11 of 14 visits
- Non-compliant visits since 2023
- 11
- 79% of visits
- Open non-compliances
- 22
- issued, in progress or ongoing
- Last assessed visit
- Apr 2026
- Non-compliant
Visits from January 1, 2023 to July 6, 2026, the comparison window. Only visits that assessed compliance are counted; consultations are not. Open means issued, in progress or ongoing when the file was taken; the other counts cover every year.
About this home
- Type
- Continuing Care Home Type B
- Subtype
- —
- Units
- 106
- City
- Red Deer
- Address
- 10 Carrington Drive, Red Deer, Alberta, T4P0S3
- Record source
- ASTRAL (as the file gives it)
- First and last visit on record
- Jan 2014 to Apr 2026
Every visit on record
Newest first. A visit that found nothing says so. Each finding shows the standard it was cited under, when it was issued, the date by which it had to be fixed, and where it stands.
April 29, 2026 · CCHSS Inspection
Non-compliant
Infection Prevention and Control — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued April 29, 2026. Fix by July 22, 2026. Status: Issued (April 29, 2026).
Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.
Issued April 29, 2026. Fix by July 22, 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 22, 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 22, 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 22, 2026. Status: Issued (April 29, 2026).
Quality Improvement Reporting — Policies and procedures for tracking incidents and near-misses are documented and implemented.
Issued April 29, 2026. Fix by July 22, 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 22, 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 22, 2026. Status: Issued (April 29, 2026).
Restraint Management and Secure Spaces — Policies and procedures regarding Restraint use are documented and implemented.
Issued April 29, 2026. Fix by July 22, 2026. Status: Issued (April 29, 2026).
Infection Prevention and Control — Staff have access to Infection Prevention and Control (IPC) equipment.
Issued April 29, 2026. Fix by July 22, 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 22, 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 22, 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 22, 2026. Status: Issued (April 29, 2026).
Risk Management — Managed risk agreements are documented and implemented.
Issued April 29, 2026. Fix by July 22, 2026. Status: Issued (April 29, 2026).
Restraint Management and Secure Spaces — Documentation for restraint use.
Issued April 29, 2026. Fix by July 22, 2026. Status: Issued (April 29, 2026).
Palliative Care and End-of-Life Care — Palliative/End-of-Life Care health care providers have access to client health information.
Issued April 29, 2026. Fix by July 22, 2026. Status: Issued (April 29, 2026).
Restraint Management and Secure Spaces — Secure Space usage is documented and reviewed by the Interdisciplinary Team.
Issued April 29, 2026. Fix by July 22, 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 22, 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 22, 2026. Status: Issued (April 29, 2026).
Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.
Issued April 29, 2026. Fix by July 22, 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 22, 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 bathing at a minimum of twice a week.
Issued April 29, 2026. Fix by July 22, 2026. Status: Issued (April 29, 2026).
April 20, 2026 · Complaint Investigation
Compliant
April 7, 2026 · CCHSS Investigation
Non-compliant
Infection Prevention and Control — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued April 7, 2026. Fix by May 8, 2026. Status: Rectified (April 7, 2026).
Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.
Issued April 7, 2026. Fix by May 8, 2026. Status: Rectified (April 7, 2026).
December 17, 2025 · Complaint Investigation
Non-compliant
Cleaning Requirements — Clean and comfortable environment
Evidence required of a clean and comfortable environment.
Issued December 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 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 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 2025).
December 17, 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 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 2025).
Safety Requirements — Accommodation is in safe condition
Evidence required that the accommodation and its grounds or common areas are safe and free of hazard
Issued December 17, 2025. Fix by January 21, 2026. Status: Rectified (December 17, 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 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 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 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 2025).
Contracted Services — Minimum contract requirements
Please ensure that contracts include a provision that addresses the handling of personal information
Issued December 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 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 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 2025).
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 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 2025).
Cleaning Requirements — Clean and comfortable environment
Evidence required of a clean and comfortable environment.
Issued December 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 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 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 2025).
Safety Requirements — Accommodation is in safe condition
Evidence required that the accommodation and its grounds or common areas are safe and free of hazard
Issued December 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 2025).
Contracted Services — Minimum contract requirements
Please ensure that contracts include a provision that addresses the handling of personal information
Issued December 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 2025).
Information Respecting the Accommodation — Signed residential services agreement
Evidence required that residential service agreement is signed by the resident/representative and an
Issued December 17, 2025. Fix by February 27, 2026. Status: Rectified (December 17, 2025).
May 13, 2025 · Complaint Investigation
Non-compliant
Personal Laundry Services — Condition of laundry facilities
Evidence required that the equipment and the laundry area are appropriate, clean and in good repair.
Issued May 13, 2025. Fix by June 16, 2025. Status: Rectified (May 13, 2025).
Concerns and Complaints — Concerns and complaints resolution
Evidence required of documented concerns received and the measures taken to resolve them.
Issued May 13, 2025. Fix by June 16, 2025. Status: Rectified (May 13, 2025).
Maintenance Requirements — Accommodation is maintained
Evidence required that the accommodation, equipment and furnishings are well maintained and in good
Issued May 13, 2025. Fix by June 16, 2025. Status: Rectified (May 13, 2025).
Maintenance Requirements — Preventative and corrective maintenance
Evidence required of a scheduled preventative maintenance and repair program.
Issued May 13, 2025. Fix by June 16, 2025. Status: Rectified (May 13, 2025).
May 13, 2025 · Inspection
Non-compliant
Personal Laundry Services — Condition of laundry facilities
Evidence required that the equipment and the laundry area are appropriate, clean and in good repair.
Issued May 13, 2025. Fix by June 16, 2025. Status: Rectified (May 13, 2025).
Concerns and Complaints — Concerns and complaints resolution
Evidence required of documented concerns received and the measures taken to resolve them.
Issued May 13, 2025. Fix by June 16, 2025. Status: Rectified (May 13, 2025).
Maintenance Requirements — Accommodation is maintained
Evidence required that the accommodation, equipment and furnishings are well maintained and in good
Issued May 13, 2025. Fix by June 16, 2025. Status: Rectified (May 13, 2025).
Safety Requirements — Accommodation is in safe condition
Evidence required that the accommodation and its grounds or common areas are safe and free of hazard
Issued May 13, 2025. Fix by May 30, 2025. Status: Rectified (May 13, 2025).
Maintenance Requirements — Preventative and corrective maintenance
Evidence required of a scheduled preventative maintenance and repair program.
Issued May 13, 2025. Fix by June 16, 2025. Status: Rectified (May 13, 2025).
May 6, 2025 · CCHSS Inspection
Non-compliant
Quality Improvement Reporting — Policies and procedures for tracking incidents and near-misses are documented and implemented.
Issued May 6, 2025. Fix by June 6, 2025. Status: Rectified (May 6, 2025).
Medication Management — Policies and procedures in Medication Management are documented and implemented.
Issued May 6, 2025. Fix by June 6, 2025. Status: Rectified (May 6, 2025).
May 6, 2025 · CCHSS Investigation
Compliant
December 5, 2024 · CCHSS Inspection
Non-compliant
Outstanding non-Compliances related to a previous Act, Regulation or Standard — For more information, please refer to results related to Long Term Care.
Issued December 5, 2024. Fix by January 15, 2025. Status: Rectified (December 5, 2024).
Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.
Issued July 30, 2024. Fix by December 5, 2024. Status: Rectified (August 1, 2024).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued July 30, 2024. Fix by January 15, 2025. Status: Rectified (August 1, 2024).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued July 30, 2024. Fix by January 15, 2025. Status: Rectified (August 1, 2024).
Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.
Issued July 30, 2024. Fix by January 15, 2025. Status: Rectified (August 1, 2024).
July 30, 2024 · CCHSS Inspection
Non-compliant
Palliative Care and End-of-Life Care — Palliative Care and End-of-Life care documentation in Care Plan.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Restraint Management and Secure Spaces — Documentation for restraint use.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Assistive Equipment, Technology And Medical/Surgical Supplies — Policies and procedures on maintaining equipment owned by Operator and reporting if unsafe.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Palliative Care and End-of-Life Care — Documented policies and procedures for Palliative and End-of-Life Care.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Safe Bath and Shower Water Temperature — Policies and procedures for water supply system and temperature checks
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Infection Prevention and Control — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Oral Care Assistance and Bathing Frequency in Continuing Care Homes — Documented bathing preference in Care Plan.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Standardized Assessment and Person-Centred Care Planning — The care plan reflects the findings of the assessment and is kept up to date.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Medication Management — Policies and procedures in Medication Management are documented and implemented.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Oral Care Assistance and Bathing Frequency in Continuing Care Homes — Policies and procedures to provide Clients the opportunity for bathing at a minimum of twice a week.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Risk Management — Managed risk agreements are documented and implemented.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Palliative Care and End-of-Life Care — Documented policies and procedures for Palliative and End-of-Life Care.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Standardized Assessment and Person-Centred Care Planning — The care plan reflects the findings of the assessment and is kept up to date.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is created and reviewed by an Interdisciplinary Team conference.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Medication Management — Policies and procedures in Medication Management are documented and implemented.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Restraint Management and Secure Spaces — Policies and procedures regarding Restraint use are documented and implemented.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Risk Management — Managed risk agreements are documented and implemented.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Oral Care Assistance and Bathing Frequency in Continuing Care Homes — Oral care assistance and bathing frequency policies and procedures are implemented.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Assistive Equipment, Technology And Medical/Surgical Supplies — Policies and procedures on maintaining equipment owned by Operator and reporting if unsafe.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Safe Bath and Shower Water Temperature — Policies and procedures for water supply system and temperature checks
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
Oral Care Assistance and Bathing Frequency in Continuing Care Homes — Policies and procedures to provide Clients the opportunity for assistance with oral care.
Issued July 30, 2024. Fix by October 25, 2024. Status: Rectified (August 1, 2024).
January 9, 2024 · Quality Monitoring Visit
Compliant
June 7, 2023 · Inspection
Non-compliant
Safety Requirements — Accommodation in safe condition
Evidence required that the accommodation and grounds are safe and free of hazards.
Issued June 7, 2023. Fix by June 8, 2023. Status: Rectified (June 7, 2023).
March 14, 2023 · CCHSS Audit
Non-compliant
CCHSS standard 1.1
An appropriate assessment tool for Client's Health Care needs is used.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 1.3
The care plan addresses the Client's needs, goals, and intervention details.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 1.8
Client's Care Plan is reviewed.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 4.4
Personal Directives, Power of Attorney, guardian/trusteeship or Advance Care Planning information.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 9.2
Policies and procedures for Staff training are documented and implemented.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 11.1
Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 12.1
Policies and procedures in Medication Management are documented and implemented.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 16.1
Policies and procedures regarding Restraint use are documented and implemented.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 16.3
Documentation for restraint use.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 16.6
Secure Space usage is documented in Client's chart and Care Plan.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 1.2
The care plan reflects the findings of the assessment and is kept up to date.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 1.3
The care plan addresses the Client's needs, goals, and intervention details.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 1.8
Client's Care Plan is reviewed.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 5.3
Palliative and End-of-Life care documentation in Care Plan.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 9.2
Policies and procedures for Staff training are documented and implemented.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 11.1
Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 12.1
Policies and procedures in Medication Management are documented and implemented.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
CCHSS standard 16.1
Policies and procedures regarding Restraint use are documented and implemented.
Issued March 14, 2023. Status: Resolved (August 8, 2023).
May 10, 2022 · Quality Monitoring Visit
Compliant
August 9, 2021 · CMOH Inspection
Compliant
August 9, 2021 · Inspection
Compliant
June 30, 2021 · CCHSS Inspection
Compliant
June 7, 2021 · Complaint Investigation
Compliant
May 28, 2021 · CCHSS Inspection
Non-compliant
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by June 30, 2021. Status: Rectified (September 2, 2021).
April 20, 2021 · CCHSS Inspection
Non-compliant
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by May 28, 2021. Status: Rectified (September 2, 2021).
March 15, 2021 · CCHSS Inspection
Non-compliant
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by April 20, 2021. Status: Rectified (September 2, 2021).
March 3, 2021 · CCHSS Inspection
Non-compliant
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 January 22, 2021. Fix by March 15, 2021. Status: Rectified (March 25, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
Medication Management — Policies and procedures in Medication Management are documented and implemented.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (March 25, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by March 15, 2021. Status: Rectified (March 4, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by March 15, 2021. Status: Rectified (March 25, 2021).
Medication Management — Policies and procedures in Medication Management are documented and implemented.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (March 25, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by March 15, 2021. Status: Rectified (September 2, 2021).
February 17, 2021 · Consultation
Not assessed (consultation)
February 17, 2021 · Consultation
Not assessed (consultation)
February 3, 2021 · CCHSS Inspection
Non-compliant
Infection Prevention and Control (IPC) — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (March 4, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Reporting reportable incidents.
Reportable incidents must be reported in accordance with the process and guidelines set out by the M
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (March 4, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by February 16, 2021. Status: Rectified (March 25, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
Medication Management — Policies and procedures in Medication Management are documented and implemented.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (March 25, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by February 16, 2021. Status: Rectified (March 4, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
Medication Management — Policies and procedures in Medication Management are documented and implemented.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (March 25, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
Infection Prevention and Control (IPC) — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (March 4, 2021).
Quality Improvement and Reporting — Reporting reportable incidents.
Reportable incidents must be reported in accordance with the process and guidelines set out by the M
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (March 4, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by February 16, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by February 16, 2021. Status: Rectified (March 25, 2021).
January 27, 2021 · CCHSS Inspection
Non-compliant
Quality Improvement and Reporting — Reporting reportable incidents.
Reportable incidents must be reported in accordance with the process and guidelines set out by the M
Issued January 22, 2021. Fix by February 3, 2021. Status: Rectified (March 4, 2021).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by February 3, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by February 3, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by February 3, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by February 3, 2021. Status: Rectified (March 4, 2021).
Medication Management — Policies and procedures in Medication Management are documented and implemented.
Issued January 22, 2021. Fix by February 3, 2021. Status: Rectified (March 25, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by February 3, 2021. Status: Rectified (September 2, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by February 3, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by February 3, 2021. Status: Rectified (March 25, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by February 3, 2021. Status: Rectified (September 2, 2021).
Infection Prevention and Control (IPC) — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued January 22, 2021. Fix by February 3, 2021. Status: Rectified (March 4, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by February 3, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Medication Management — Policies and procedures in Medication Management are documented and implemented.
Issued January 22, 2021. Fix by February 19, 2021. Status: Rectified (March 25, 2021).
Infection Prevention and Control (IPC) — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (March 4, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by March 31, 2021. Status: Rectified (March 25, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Reporting reportable incidents.
Reportable incidents must be reported in accordance with the process and guidelines set out by the M
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (March 4, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
January 22, 2021 · CCHSS Audit
Non-compliant
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Infection Prevention and Control (IPC) — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (March 4, 2021).
Medication Management — Policies and procedures in Medication Management are documented and implemented.
Issued January 22, 2021. Fix by February 19, 2021. Status: Rectified (March 25, 2021).
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 January 22, 2021. Fix by March 31, 2021. Status: Rectified (March 4, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by February 19, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by February 19, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by January 22, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Reporting reportable incidents.
Reportable incidents must be reported in accordance with the process and guidelines set out by the M
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (March 4, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
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 January 22, 2021. Fix by February 19, 2021. Status: Rectified (March 25, 2021).
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 January 22, 2021. Fix by March 31, 2021. Status: Rectified (March 25, 2021).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Reporting reportable incidents.
Reportable incidents must be reported in accordance with the process and guidelines set out by the M
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (March 4, 2021).
Medication Management — Policies and procedures in Medication Management are documented and implemented.
Issued January 22, 2021. Fix by February 19, 2021. Status: Rectified (March 25, 2021).
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 January 22, 2021. Fix by February 19, 2021. Status: Rectified (September 2, 2021).
Infection Prevention and Control (IPC) — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (March 4, 2021).
Restraint Management — Documentation for restraint use.
Issued January 22, 2021. Fix by February 19, 2021. Status: Rectified (September 2, 2021).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued January 22, 2021. Fix by February 19, 2021. Status: Rectified (September 2, 2021).
Quality Improvement and Reporting — Quality improvement policies and programs are documented and implemented.
An operator must establish, implement, and maintain documented quality improvement policies and prog
Issued January 22, 2021. Fix by February 19, 2021. Status: Rectified (September 2, 2021).
Staff Training — Policies and procedures for Staff training are documented and implemented.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
Risk Management — Managed risk agreements are documented and implemented.
Issued January 22, 2021. Fix by March 31, 2021. Status: Rectified (September 2, 2021).
January 21, 2021 · CMOH Inspection
Non-compliant
COVID-19 Chief Medical Officer of Health Orders Expectations Not Met — Entry Screening Process
Issued January 21, 2021. Fix by January 23, 2021. Status: Rectified (January 25, 2021).
January 21, 2021 · Complaint Investigation
Compliant
January 21, 2021 · Inspection
Non-compliant
Resident Safety and Security — Incident reporting
Please submit completed reportable incident form for the incident on DATE within one business day.
Issued January 21, 2021. Fix by February 28, 2021. Status: Rectified (February 17, 2021).
December 18, 2020 · Complaint Investigation
Compliant
November 5, 2020 · CMOH Inspection
Non-compliant
COVID-19 Chief Medical Officer of Health Orders Expectations Not Met — Entry Screening Process
Issued November 5, 2020. Fix by November 7, 2020. Status: Rectified (November 9, 2020).
COVID-19 Chief Medical Officer of Health Orders Expectations Not Met — Entry Screening Process
Issued November 5, 2020. Fix by November 7, 2020. Status: Rectified (November 9, 2020).
COVID-19 Chief Medical Officer of Health Orders Expectations Not Met — Shared Spaces
Issued November 5, 2020. Fix by November 7, 2020. Status: Rectified (November 6, 2020).
November 3, 2020 · Quality Monitoring Visit
Non-compliant
standard not recorded in the file
Issued November 3, 2020. Status: Resolved (December 18, 2020).
standard not recorded in the file
Issued November 3, 2020. Status: Resolved (December 18, 2020).
standard not recorded in the file
Issued November 3, 2020. Status: Resolved (December 18, 2020).
standard not recorded in the file
Issued November 3, 2020. Status: Resolved (December 18, 2020).
standard not recorded in the file
Issued November 3, 2020. Status: Resolved (December 18, 2020).
standard not recorded in the file
Issued November 3, 2020. Status: Resolved (December 18, 2020).
standard not recorded in the file
Issued November 3, 2020. Status: Resolved (December 18, 2020).
standard not recorded in the file
Issued November 3, 2020. Status: Resolved (December 18, 2020).
standard not recorded in the file
Issued November 3, 2020. Status: Resolved (December 18, 2020).
standard not recorded in the file
Issued November 3, 2020. Status: Resolved (December 18, 2020).
April 3, 2020 · Consultation
Not assessed (consultation)
January 7, 2020 · Inspection
Non-compliant
Duties of an Operator — Take all Concerns into Consideration
Provide evidence that all requests, concerns and proposed solutions expressed by a_x000D_ resident, a me
Issued January 7, 2020. Fix by March 31, 2020. Status: Rectified (February 7, 2020).
Duties of an Operator — Take all Concerns into Consideration
Provide evidence that all requests, concerns and proposed solutions expressed by a_x000D_ resident, a me
Issued January 7, 2020. Fix by March 31, 2020. Status: Rectified (February 7, 2020).
January 7, 2020 · Inspection
Compliant
July 22, 2019 · Inspection
Compliant
July 22, 2019 · Inspection
Compliant
February 28, 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 February 28, 2019. Status: Resolved (October 4, 2019).
CCHSS standard 1.3
The care plan addresses the Client's needs, goals, and intervention details.
Issued February 28, 2019. Status: Resolved (October 4, 2019).
CCHSS standard 1.8
Client's Care Plan is reviewed.
Issued February 28, 2019. Status: Resolved (October 4, 2019).
CCHSS standard 9.2
Policies and procedures for Staff training are documented and implemented.
Issued February 28, 2019. Status: Resolved (October 4, 2019).
CCHSS standard 10.1
Managed risk agreements are documented and implemented.
Issued February 28, 2019. Status: Resolved (October 4, 2019).
CCHSS standard 12.1
Policies and procedures in Medication Management are documented and implemented.
Issued February 28, 2019. Status: Resolved (October 4, 2019).
CCHSS standard 16.1
Policies and procedures regarding Restraint use are documented and implemented.
Issued February 28, 2019. Status: Resolved (October 4, 2019).
CCHSS standard 16.3
Documentation for restraint use.
Issued February 28, 2019. Status: Resolved (October 4, 2019).
January 22, 2019 · Inspection
Compliant
January 22, 2019 · Inspection
Non-compliant
Safety Requirements — Accommodation in safe condition
Evidence required that the accommodation and grounds are safe and free of hazards.
Issued January 22, 2019. Fix by February 28, 2019. Status: Rectified (February 25, 2019).
Residents Personal Affairs — Communication of processes
Evidence required that the policies on involvement in residents' personal affairs have been communic
Issued January 22, 2019. Fix by February 28, 2019. Status: Rectified (February 25, 2019).
Maintenance Requirements — Preventative and corrective maintenance
Evidence required of a scheduled preventative maintenance and repair program.
Issued January 22, 2019. Fix by February 28, 2019. Status: Rectified (February 25, 2019).
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 January 22, 2019. Fix by February 28, 2019. Status: Rectified (February 25, 2019).
Cleaning Requirements — Regularly scheduled cleaning of all areas
Evidence required that the accommodation is cleaned on a regularly scheduled basis.
Issued January 22, 2019. Fix by February 28, 2019. Status: Rectified (February 25, 2019).
Laundry — Condition of laundry facilities
Evidence required that the equipment and the laundry area are appropriate, clean and in good repair.
Issued January 22, 2019. Fix by February 28, 2019. Status: Rectified (February 25, 2019).
Information Respecting the Supportive Living Accommodation — Accommodation information provision
Evidence required that the information is made available regarding:
Issued January 22, 2019. Fix by May 31, 2019. Status: Rectified (March 6, 2019).
Information Respecting the Supportive Living Accommodation — Signed residential services agreement
Evidence required that residential service agreements have been signed by the resident/representativ
Issued January 22, 2019. Fix by February 28, 2019. Status: Rectified (February 25, 2019).
Resident Safety and Security — Maintenance and inspection of security systems
Evidence required that the security system is maintained, inspected and tested.
Issued January 22, 2019. Fix by February 28, 2019. Status: Rectified (February 25, 2019).
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 p
Issued January 22, 2019. Fix by February 28, 2019. Status: Rectified (February 25, 2019).
Resident Safety and Security — Suitability, maintenance and inspection of communication/emergency call/communication system
Evidence required that the emergency call/communication system is maintained, inspected and tested.
Issued January 22, 2019. Fix by February 28, 2019. Status: Rectified (February 25, 2019).
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 January 22, 2019. Fix by February 28, 2019. Status: Rectified (February 25, 2019).
Prevention of Abuse — Education on prevention, identification and reporting abuse
Evidence required that demonstrates that all employees have received appropriate education respectin
Issued January 22, 2019. Fix by February 28, 2019. Status: Rectified (February 25, 2019).
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 January 22, 2019. Fix by May 31, 2019. Status: Rectified (February 25, 2019).
Maintenance Requirements — Preventative and corrective maintenance
Evidence required of a scheduled preventative maintenance and repair program.
Issued January 22, 2019. Fix by May 31, 2019. Status: Rectified (February 25, 2019).
Resident Safety and Security — Suitability, maintenance and inspection of communication/emergency call/communication system
Evidence required that the emergency call/communication system is maintained, inspected and tested.
Issued January 22, 2019. Fix by May 31, 2019. Status: Rectified (February 25, 2019).
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 January 22, 2019. Fix by May 31, 2019. Status: Rectified (February 25, 2019).
Prevention of Abuse — Education on prevention, identification, and reporting abuse
Evidence required that demonstrates that all employees have received appropriate education respectin
Issued January 22, 2019. Fix by May 31, 2019. Status: Rectified (February 25, 2019).
Information Respecting the Long Term Care Accommodation — Accommodation information provision
Evidence required that information is made available to applicants and residents and their represent
Issued January 22, 2019. Fix by May 31, 2019. Status: Rectified (March 6, 2019).
Residents Personal Affairs — Communication of processes
Evidence required that the policies on involvement in residents' personal affairs have been communic
Issued January 22, 2019. Fix by May 31, 2019. Status: Rectified (February 25, 2019).
Cleaning Requirements — Regularly scheduled cleaning of all areas
Evidence required that the accommodation is cleaned on a regularly scheduled basis.
Issued January 22, 2019. Fix by May 31, 2019. Status: Rectified (March 6, 2019).
Laundry — Condition of laundry facilities
Evidence required that the equipment and the laundry area are appropriate, clean and in good repair.
Issued January 22, 2019. Fix by May 31, 2019. Status: Rectified (February 25, 2019).
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 January 22, 2019. Fix by May 31, 2019. Status: Rectified (February 25, 2019).
Bedding — Quality and regularly scheduled bedding and towel changes
Evidence required that bedding is in good condition and changed on a regularly scheduled basis.
Issued January 22, 2019. Fix by May 31, 2019. Status: Rectified (February 25, 2019).
Resident Safety and Security — Maintenance and inspection of security systems
Evidence required that the security system is maintained, inspected and tested.
Issued January 22, 2019. Fix by May 31, 2019. Status: Rectified (February 25, 2019).
July 24, 2018 · CCHSS Audit
Non-compliant
CCHSS standard 1.1
An appropriate assessment tool for Client's Health Care needs is used.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 1.2
The care plan reflects the findings of the assessment and is kept up to date.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 1.3
The care plan addresses the Client's needs, goals, and intervention details.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 1.5
Client and/or Client's legal representative participate in the development and review of Care Plan.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 1.7
Client's Care Plan is created and reviewed by an Interdisciplinary Team conference.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 1.8
Client's Care Plan is reviewed.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 6.3
Policies and procedures on maintaining equipment owned by Operator and reporting if unsafe.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 9.2
Policies and procedures for Staff training are documented and implemented.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 10.1
Managed risk agreements are documented and implemented.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 11.1
Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 12.1
Policies and procedures in Medication Management are documented and implemented.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 15.1
Policies and procedures regarding safe water temperatures are documented and implemented.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 15.2
Policies and procedures for water supply system and temperature checks
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 16.1
Policies and procedures regarding Restraint use are documented and implemented.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
CCHSS standard 16.3
Documentation for restraint use.
Issued July 24, 2018. Status: Resolved (February 27, 2019).
July 12, 2018 · Inspection
Compliant
January 17, 2018 · Inspection
Compliant
January 20, 2017 · Inspection
Compliant
August 10, 2016 · CCHSS Audit
Non-compliant
Assistive Equipment, Technology and Medical/Surgical Supplies — Instruction on appropriate and safe use of Operator owned equipment.
An operator must ensure that instruction on the appropriate and safe use of the operator owned assis
Issued August 10, 2016. Fix by October 12, 2016. Status: Rectified (October 13, 2016).
Infection Prevention and Control (IPC) — Infection Prevention and Control (IPC) policies and procedures are documented and implemented.
Issued August 10, 2016. Fix by October 12, 2016. Status: Rectified (October 13, 2016).
Medication Management — Policies and procedures in Medication Management are documented and implemented.
Issued August 10, 2016. Fix by October 12, 2016. Status: Rectified (October 13, 2016).
Palliative and End-Of-Life Care — Palliative and End-of-Life care documentation in Care Plan.
Issued August 10, 2016. Fix by October 12, 2016. Status: Rectified (October 13, 2016).
Restraint Management — Policies and procedures regarding Restraint use are documented and implemented.
Issued August 10, 2016. Fix by October 12, 2016. Status: Rectified (October 13, 2016).
Risk Management — Managed risk agreements are documented and implemented.
Issued August 10, 2016. Fix by October 12, 2016. Status: Rectified (October 13, 2016).
Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is created and reviewed by an Interdisciplinary Team conference.
Issued August 10, 2016. Fix by October 12, 2016. Status: Rectified (October 13, 2016).
Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.
Issued August 10, 2016. Fix by October 26, 2016. Status: Rectified (October 13, 2016).
Standardized Assessment and Person-Centred Care Planning — The care plan addresses the Client's needs, goals, and intervention details.
Issued August 10, 2016. Fix by November 30, 2016. Status: Rectified (December 1, 2016).
Standardized Assessment and Person-Centred Care Planning — The care plan reflects the findings of the assessment and is kept up to date.
Issued August 10, 2016. Fix by November 30, 2016. Status: Rectified (December 1, 2016).
January 19, 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 January 19, 2016. Fix by April 30, 2016. Status: Rectified (April 20, 2016).
January 15, 2015 · Inspection
Non-compliant
Safety and Security — Policies and procedures
Evidence required of the site specific policies and procedures in place regarding resident safety an
Issued January 15, 2015. Fix by February 28, 2015. Status: Rectified (February 18, 2015).
July 15, 2014 · Inspection
Non-compliant
Privacy and Personal Information — Protection of information and privacy
Evidence required that the privacy and personal information of residents are protected.
Issued July 15, 2014. Fix by January 31, 2015. Status: Rectified (January 5, 2015).
Assessment — Resident assessments
Evidence required that assessments are completed on applicants for residency.
Issued January 15, 2014. Fix by January 31, 2015. Status: Rectified (January 5, 2015).
Water Temperature — Therapeutic tub temperature checks
Evidence required of the testing of the temperature of the hottest flowing water from each therapeut
Issued July 15, 2014. Fix by October 31, 2014. Status: Rectified (October 16, 2014).
Continuation of Services — Contingency plans
Evidence required that the continuation of services plan includes provisions for loss of utilities,
Issued January 15, 2014. Fix by January 31, 2015. Status: Rectified (January 5, 2015).
Cleaning Requirements — Regularly scheduled cleaning of all areas
Evidence required that the accommodation is cleaned on a regularly scheduled basis.
Issued July 15, 2014. Fix by September 30, 2014. Status: Rectified (September 24, 2014).
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 July 15, 2014. Fix by September 30, 2014. Status: Rectified (September 24, 2014).
Safety Requirements — Accommodation in safe condition
Evidence required that the accommodation and grounds are safe and free of hazards.
Issued July 15, 2014. Fix by September 30, 2014. Status: Rectified (September 24, 2014).
January 30, 2014 · Inspection
Non-compliant
Assessment — Resident assessments
Evidence required that assessments are completed on applicants for residency.
Issued January 15, 2014. Fix by July 31, 2014. Status: Rectified (January 5, 2015).
Continuation of Services — Contingency plans
Evidence required that the continuation of services plan includes provisions for loss of utilities,
Issued January 15, 2014. Fix by July 31, 2014. Status: Rectified (January 5, 2015).
Information Respecting the Supportive Living Accommodation — Accommodation information provision
Evidence required that the information is made available regarding:
Issued January 15, 2014. Fix by May 31, 2014. Status: Rectified (March 27, 2014).
Concerns and Complaints — Concerns and complaints resolution
Evidence required of documented concerns received and the measures taken to resolve them.
Issued January 15, 2014. Fix by May 31, 2014. Status: Rectified (March 27, 2014).
January 21, 2014 · Inspection
Non-compliant
Assessment — Resident assessments
Evidence required that assessments are completed on applicants for residency.
Issued January 15, 2014. Fix by March 31, 2014. Status: Rectified (January 5, 2015).
Information Respecting the Supportive Living Accommodation — Accommodation information provision
Evidence required that the information is made available regarding:
Issued January 15, 2014. Fix by March 31, 2014. Status: Rectified (March 27, 2014).
Laundry — Condition of laundry facilities
Evidence required that the equipment and the laundry area are appropriate, clean and in good repair.
Issued January 21, 2014. Fix by March 31, 2014. Status: Rectified (January 30, 2014).
Continuation of Services — Contingency plans
Evidence required that the continuation of services plan includes provisions for loss of utilities,
Issued January 15, 2014. Fix by March 31, 2014. Status: Rectified (January 5, 2015).
Concerns and Complaints — Concerns and complaints resolution
Evidence required of documented concerns received and the measures taken to resolve them.
Issued January 15, 2014. Fix by March 31, 2014. Status: Rectified (March 27, 2014).
Resident Safety and Security — Suitability, maintenance and inspection of communication/emergency call/communication system
Evidence required that the emergency call/communication system is maintained, inspected and tested.
Issued January 15, 2014. Fix by March 31, 2014. Status: Rectified (January 30, 2014).
January 15, 2014 · 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 January 15, 2014. Fix by March 31, 2014. Status: Rectified (January 21, 2014).
Information Respecting the Supportive Living Accommodation — Accommodation information provision
Evidence required that the information is made available regarding:
Issued January 15, 2014. Fix by March 31, 2014. Status: Rectified (March 27, 2014).
Resident Safety and Security — Suitability, maintenance and inspection of communication/emergency call/communication system
Evidence required that the emergency call/communication system is maintained, inspected and tested.
Issued January 15, 2014. Fix by March 31, 2014. Status: Rectified (January 30, 2014).
Concerns and Complaints — Concerns and complaints resolution
Evidence required of documented concerns received and the measures taken to resolve them.
Issued January 15, 2014. Fix by March 31, 2014. Status: Rectified (March 27, 2014).
Continuation of Services — Practicability, communication and review of plans
Evidence required that the continuation of services plan is communicated and made available to resid
Issued January 15, 2014. Fix by March 31, 2014. Status: Rectified (January 21, 2014).
Assessment — Resident assessments
Evidence required that assessments are completed on applicants for residency.
Issued January 15, 2014. Fix by March 31, 2014. Status: Rectified (January 5, 2015).
Continuation of Services — Contingency plans
Evidence required that the continuation of services plan includes provisions for loss of utilities,
Issued January 15, 2014. Fix by March 31, 2014. Status: Rectified (January 5, 2015).
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 January 15, 2014. Fix by March 31, 2014. Status: Rectified (January 21, 2014).
Questions to ask on a visit
Built from the standards this home was cited under, not from anything we found. Ask how it meets each one today.
- 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: Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.?
- How does the home meet: Standardized Assessment and Person-Centred Care Planning — Medical Status assessments are documented.?
- How does the home meet: Continuity of Health Care — Emergency preparedness, pandemic, contingency plans mitigate risks, are reviewed and communicated.?
- How does the home meet: Staff Training — Policies and procedures for Staff training are documented and implemented.?
- How does the home meet: Quality Improvement Reporting — Policies and procedures for tracking incidents and near-misses are documented and implemented.?
Homes nearby
Straight-line distance between postal code centres (in rural Alberta, town centres). Each home’s share of non-compliant visits since 2023, on the same method as the city pages.
| Home | Type | Distance | Non-compliant |
|---|---|---|---|
| Pines LodgeRed Deer · 84 units | Lodge | under 1 km | 0%0 of 2 visits |
| Timberstone MewsRed Deer · 60 units | Type B (designated supportive living) | under 1 km | 86%6 of 7 visits |
| Michener Services - Residential Supports - 11A1 Michener WayRed Deer · 10 units | Group home | 1.1 km | —no visits in the window |
| Michener Services - Residential Supports - 11A3 Michener WayRed Deer · 7 units | Group home | 1.1 km | —no visits in the window |
| Michener Services - Residential Supports - 22A1 Michener WayRed Deer · 6 units | Group home | 1.1 km | —no visits in the window |
| Michener Services - Residential Supports - Michener Terrace East 2Red Deer · 6 units | Group home | 1.1 km | 100%1 of 1 visit |
Check the government’s record
- Official record on the government’s viewer
- Official record on the government’s viewer
- Official record on the government’s viewer
- Official record on the government’s viewer
Inspections are a snapshot. Visit, ask for the home’s latest inspection report, and ask the questions above. Concerns about a specific visit go to the home first, then to the Continuing Care Licensing Office (cclo@gov.ab.ca).
Source: Government of Alberta, Continuing Care Accommodation Standards compliance reporting on Open Alberta (Open Government Licence – Alberta), file of —, with visits to July 6, 2026. Results are as the government recorded them. An inspection is a snapshot. The official record and the finding text are on the government’s viewer; the dates and statuses here come from the file. How this is built.