Vilna Lodge

1. February 5, 2026 · CCHSS Inspection

   Non-compliant

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

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

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

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

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

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

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 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 February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

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

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

   • Health Care Providers — Active registration is verified and documented for Regulated Health Care Professionals.

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 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 February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

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

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

   • Health Care Providers — Job descriptions and guidelines are provided for Health Care Providers.

     An operator must provide the health care providers it employs with access to current information on

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

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

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

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

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

   • Staff Training — Documented compliance to training.

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

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

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

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

   • Client Access to Information — Personal Directives, Power of Attorney, guardian/trusteeship or Advance Care Planning information.

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

   • Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is created and reviewed by an Interdisciplinary Team conference.

     Issued February 5, 2026. Fix by April 30, 2026. Status: Rectified (February 5, 2026).

2. June 7, 2023 · Inspection

   Non-compliant

   • 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 June 7, 2023. Fix by July 31, 2023. Status: Rectified (July 20, 2023).

3. September 27, 2022 · CCHSS Audit

   Non-compliant

   • CCHSS standard 1.2

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

     Issued September 27, 2022. Status: Resolved (February 1, 2023).

   • CCHSS standard 1.7

     Client's Care Plan is created and reviewed by an Interdisciplinary Team conference.

     Issued September 27, 2022. Status: Resolved (February 1, 2023).

   • CCHSS standard 1.8

     Client's Care Plan is reviewed.

     Issued September 27, 2022. Status: Resolved (February 1, 2023).

   • CCHSS standard 5.3

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

     Issued September 27, 2022. Status: Resolved (February 1, 2023).

   • CCHSS standard 11.1

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

     Issued September 27, 2022. Status: Resolved (February 1, 2023).

   • CCHSS standard 12.1

     Policies and procedures in Medication Management are documented and implemented.

     Issued September 27, 2022. Status: Resolved (February 1, 2023).

   • CCHSS standard 15.2

     Policies and procedures for water supply system and temperature checks

     Issued September 27, 2022. Status: Resolved (February 1, 2023).

   • CCHSS standard 16.1

     Policies and procedures regarding Restraint use are documented and implemented.

     Issued September 27, 2022. Status: Resolved (February 1, 2023).

   • CCHSS standard 16.3

     Documentation for restraint use.

     Issued September 27, 2022. Status: Resolved (February 1, 2023).

   • CCHSS standard 16.6

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

     Issued September 27, 2022. Status: Resolved (February 1, 2023).

4. February 23, 2022 · Complaint Investigation

   Non-compliant

   • COVID-19 Chief Medical Officer of Health Orders Expectations Not Met — COVID Outbreak Policies, Procedures and Implementation

     Issued February 23, 2022. Fix by February 28, 2022. Status: Rectified (February 28, 2022).

5. February 23, 2022 · CMOH Inspection

   Non-compliant

   • COVID-19 Chief Medical Officer of Health Orders Expectations Not Met — COVID Outbreak Policies, Procedures and Implementation

     Issued February 23, 2022. Fix by February 25, 2022. Status: Rectified (February 23, 2022).

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

     Issued February 23, 2022. Fix by February 25, 2022. Status: Rectified (February 23, 2022).

   • COVID-19 Chief Medical Officer of Health Orders Expectations Not Met — COVID Outbreak Policies, Procedures and Implementation

     Issued February 23, 2022. Fix by February 28, 2022. Status: Rectified (February 28, 2022).

6. February 2, 2022 · Quality Monitoring Visit

   Compliant

7. June 17, 2021 · CMOH Inspection

   Compliant

8. June 17, 2021 · Complaint Investigation

   Compliant

9. March 30, 2021 · CMOH Inspection

   Non-compliant

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

     Issued March 30, 2021. Fix by April 9, 2021. Status: Rectified (April 9, 2021).

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

     Issued March 30, 2021. Fix by April 9, 2021. Status: Rectified (April 9, 2021).

10. March 30, 2021 · Complaint Investigation

    Non-compliant

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

      Issued March 30, 2021. Fix by April 9, 2021. Status: Rectified (April 9, 2021).

11. April 6, 2020 · Consultation

    Not assessed (consultation)

12. February 18, 2020 · Inspection

    Compliant

13. February 18, 2020 · Inspection

    Compliant

14. February 20, 2019 · Inspection

    Compliant

15. February 20, 2019 · Inspection

    Compliant

16. February 1, 2018 · Inspection

    Compliant

17. February 8, 2017 · Inspection

    Compliant

18. November 3, 2016 · CCHSS Audit

    Compliant

19. February 4, 2016 · Inspection

    Compliant

20. February 11, 2015 · Inspection

    Non-compliant

    • Water Temperature — Safe water temperatures

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

      Issued February 11, 2015. Fix by March 31, 2015. Status: Rectified (February 20, 2015).

21. August 19, 2014 · CCHSS Regular Audit

    Non-compliant

    • Medication Management — Medication management policies and processes are inclusive as defined by the Standards.

      (f) Medication management policies and processes include:_x000D_ _x000D_ - Simple and easy to unde

      Issued August 19, 2014. Fix by October 20, 2014. Status: Rectified (September 26, 2014).

    • Operational Processes — Policies and processes are in place as defined by the Standard.

      (b) Operational policies and processes shall include, but are not limited to:_x000D_ - Client heal

      Issued August 19, 2014. Fix by October 27, 2014. Status: Rectified (October 27, 2014).

    • Quality Improvement — Facility/program has a quality improvement program as defined by the Standards.

      (a) The facility or program has an established quality improvement program that includes:_x000D_ -

      Issued August 19, 2014. Fix by October 27, 2014. Status: Rectified (October 8, 2014).

    • Standardized Assessments — RAPS/CAPS reviewed and considered when preparing the client care plan.

      (h) RAPS/CAPS, are reviewed and considered when preparing the client care plan.

      Issued August 19, 2014. Fix by October 27, 2014. Status: Rectified (October 27, 2014).

22. February 18, 2014 · Inspection

    Non-compliant

    • Job Descriptions — Job descriptions for each employee

      Evidence required of a written job description for each employee.

      Issued February 18, 2014. Fix by April 30, 2014. Status: Rectified (February 12, 2015).

    • Maintenance Requirements — Preventative and corrective maintenance

      Evidence required of a scheduled preventative maintenance and repair program.

      Issued February 18, 2014. Fix by April 30, 2014. Status: Rectified (February 12, 2015).

• How does the home meet: Oral Care Assistance and Bathing Frequency in Continuing Care Homes — Policies and procedures to provide Clients the opportunity for assistance with oral care.?
• How does the home meet: Medication Management — Policies and procedures in Medication Management are documented and implemented.?
• How does the home meet: Continuity of Health Care — Documented emergency preparedness, pandemic and contingency plan.?
• How does the home meet: Standardized Assessment and Person-Centred Care Planning — An appropriate assessment tool for Client's Health Care needs is used.?
• How does the home meet: Standardized Assessment and Person-Centred Care Planning — Client's Care Plan is reviewed.?
• How does the home meet: Health Care Providers — Active registration is verified and documented for Regulated Health Care Professionals.?

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