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01 - June 9, 2026 Homes Committee of Management Agenda PackageOZ5 ElgmCounty Homes Committee of Management Orders of the Day Tuesday, June 9, 2026, 11:00 a.m. Council Chambers 450 Sunset Drive St. Thomas ON Note for Members of the Public: Please click the link below to watch the meeting livestream: https://video.isilive.ca/elgincounty/live.html Accessible formats available upon request. 1. Call to Order 2. Election of Chair and Vice Chair 3. Approval of Agenda 4. Adoption of Minutes 5. Disclosure of Pecuniary Interest and the General Nature Thereof 6. Delegations 7. Reports/Briefings 7.1 Director of Homes and Seniors Services - First Quarter Homes Review 8. Other Business 9. Correspondence 10. Closed Meeting Items 11. Motion to Rise and Report 12. Date of Next Meeting 13. Adjournment Pages 2 67 Homes Committee of Management Minutes November 25, 2025, 1:30 p.m. Council Chambers 450 Sunset Drive St. Thomas ON Members Present: Warden Grant Jones Deputy Warden Ed Ketchabaw Councillor Dominique Giguere Councillor Mark Widner Councillor Jack Couckuyt Councillor Todd Noble Councillor Mike Hentz Councillor Richard Leatham Members Absent: Councillor Andrew Sloan Staff Present: Blaine Parkin, Chief Administrative Officer/Clerk Michele Harris, Director of Homes and Seniors Services Holly Hurley, Director of People & Culture Katherine Thompson, Manager of Administrative Services/Deputy Clerk Jenna Fentie, Legislative Services Coordinator Stefanie Heide, Legislative Services Coordinator 1. Call to Order The meeting was called to order at 2.17 p.m. with Warden Jones in the chair. 2. Approval of Agenda Resolution Number: HCM25-10 Moved by: Deputy Warden Ketchabaw Seconded by: Councillor Hentz RESOLVED THAT the agenda for the November 25, 2025 Homes Committee of Management meeting be approved as presented. Page 2 of 54 Motion Carried. 3. Adoption of Minutes Resolution Number: HCM25-11 Moved by: Councillor Leatham Seconded by: Councillor Giguere RESOLVED THAT the minutes of the meeting held on August 12, 2025 be adopted. Motion Carried. 4. Disclosure of Pecuniary Interest and the General Nature Thereof None. 5. Delegations None. 6. Reports/Briefings 6.1 Director of Homes and Seniors Services - Homes — Committee of Management — Long -Term Care Director's Update July 1, 2025 — September 30, 2025 The Director of Homes and Seniors Services presented the report that provides an overview of recent updates and Ontario Health, Ministry of Health, and Ministry of Long -Term Care announcements which impact the three (3) Elgin County Long -Term Care Homes services and operations for the period of July 1, 2025 - September 30, 2025. 6.2 Director of Homes and Seniors Services - Homes — Committee of Management — Long -Term Care Operational Report July 1, 2025 — September 30, 2025 The Director of Homes and Seniors Services presented the report that provides an overview of the day to day operations of the three (3) Elgin County Long -Term Care Homes along with pertinent departmental and committee updates and inspections for the period of July 1, 2025 - September 30, 2025. Resolution Number: HCM25-11 Moved by: Deputy Warden Ketchabaw Seconded by: Councillor Noble RESOLVED THAT the report titled "Homes — Committee of Management — Long -Term Care Director's Update July 1, 2025 — September 30, 2025" from the Director of Homes and Seniors Services dated November 25, 2 Page 3of54 2025 be received and filed; and THAT the report titled "Homes - Committee of Management — Long -Term Care Operational Report July 1, 2025 — September 30, 2025" from the Director of Homes and Seniors Services dated November 25, 2025 be received and filed. Motion Carried. 7. Other Business I101rem 8. Correspondence None. 9. Closed Meeting Items None. 10. Motion to Rise and Report None. 11. Date of Next Meeting The next Homes Committee of Management meeting will be held at the call of the Chair. 12. Adjournment Resolution Number: HCM25-12 Moved by: Councillor Widner Seconded by: Councillor Leatham RESOLVED THAT we do now adjourn at 2.34 p.m. to meet at the call of the Chair. Motion Carried. Katherine Thompson, County Clerk/Manager of Administrative Services. Chair. 3 Page 4of54 ElginCounty Report to Homes Committee of Management From: Joe Anne Holloway, Director of Homes and Senior Services Date: May 5, 2026 Subject: First Quarter Homes Review Recommendation(s): THAT the report titled Homes First Quarter Review form the Director of Home and Senior Services dated May 5, 2026, be received and filed. Introduction: This quarterly review highlights the continued strength and progress of the Elgin County long-term care homes as we remain committed to delivering exceptional care and service. Over the past quarter, our teams have demonstrated dedication, compassion, and resilience while advancing operational goals and enhancing the quality of life for the residents we are privileged to serve. The achievements outlined in this report reflect the collaborative efforts of leadership and frontline staff working together to foster safe, supportive, and thriving home communities. The attached score cards for each of the homes will support the information in this report. Background and Discussion: The first quarter of this year has been marked by strong organizational performance and meaningful progress across the Elgin County long-term care homes. Through strategic leadership, disciplined financial management, collaborative labour relations, and an unwavering commitment to quality resident care, the homes have established a solid foundation for continued success in the months ahead. Despite the ongoing complexities within the long-term care sector, our homes have remained focused on operational excellence, sustainability, and the delivery of compassionate, high -quality care. The accomplishments achieved during this quarter reflect the dedication of our leadership teams, frontline staff, and corporate supports, all working together toward shared goals. A key area of focus during the first quarter was maintaining strong financial stewardship across all homes. Through careful budget monitoring, regular financial reviews, and disciplined oversight of expenditures, the homes successfully kept finances on track Page 5of54 while continuing to meet the operational needs of each home. Leadership teams worked diligently to monitor labour costs, agency utilization, occupancy levels, and departmental spending to ensure resources were allocated effectively and responsibly. This level of financial vigilance allowed the homes to remain aligned with budget expectations while continuing to invest in resident care, staffing stability, and essential services. The ability to maintain fiscal responsibility while navigating rising costs and sector pressures demonstrates the strength of the organization's financial planning processes and its commitment to long-term sustainability. In addition to budget management, a comprehensive review of existing service contracts and vendor agreements was undertaken during the quarter to identify opportunities for greater efficiency, improved service delivery, and cost savings. These reviews ensured that contracted services continued to meet the needs of the homes while providing value and accountability. Opportunities were identified to renegotiate terms, improve service expectations, and align partnerships with the strategic priorities of the organization. This proactive approach not only strengthened operational oversight but also reinforced the organization's commitment to responsible resource management. By carefully evaluating contractual relationships, the homes are better positioned to maximize value while maintaining the high standards required to support quality resident care. Labour relations and workforce engagement also remained a central priority throughout the first quarter. Recognizing that staff are the foundation of quality care, leadership teams invested significant time in building positive relationships with employees and union representatives. Through open communication, regular meetings, and collaborative problem -solving, the homes worked to address concerns proactively, resolve issues respectfully, and foster a culture of mutual trust and accountability. This collaborative labour approach has supported workplace stability while strengthening staff engagement. By maintaining productive union relationships and ensuring transparency in decision -making, the organization is working to create an environment where staff feel heard, valued, and empowered to contribute to the success of the homes. At the same time, efforts to support recruitment and retention continued to be a major focus. Leadership teams reviewed staffing patterns, monitored vacancies, and implemented strategies to support workforce stability while minimizing disruptions to resident care. They then work with the People and Culture team to ensure vacancies are filled in a timely manor. These efforts included optimizing scheduling practices, supporting employee attendance initiatives, and promoting a workplace culture centered on teamwork and recognition. The homes understand that a stable and engaged workforce is critical to maintaining high -quality care, and the progress achieved in this area during the first quarter has strengthened operational consistency and team performance across the homes. Above all, the homes remained deeply committed to providing excellent care and service to residents. Throughout the quarter, teams across all three homes continued to demonstrate professionalism, compassion, and dedication in delivering resident - centered care that promotes dignity, safety, and quality of life. Quality indicators were closely monitored, and leadership teams remained focused on achieving positive Page 6of54 outcomes in areas such as clinical care, infection prevention and control, resident satisfaction, and regulatory compliance. Staff worked diligently to maintain care standards, support resident well-being, and respond effectively to the evolving needs of those living within our homes. This commitment to excellence was reflected in the quality of care delivered each day and in the positive experiences of residents and families. Quality improvement initiatives also continued to advance during the quarter, supporting the organization's goal of ongoing enhancement in all aspects of care and service delivery. Leadership teams reviewed performance indicators, analyzed trends, and implemented action plans where opportunities for improvement were identified. These efforts supported evidence -based decision -making and promoted accountability supported by being a Best Practice Spotlight Organization. By maintaining a strong focus on continuous quality improvement, the homes are not only meeting required BPSO standards but actively striving to exceed expectations in the care and services they provide. The homes also maintained strong and positive relationships with ministry representatives and regulatory partners throughout the first quarter. Open communication, timely responsiveness, and consistent compliance efforts reinforced the organization's reputation as a credible and reliable provider within the sector. This is reinforced by the outcomes of the ministry compliance reports. Leadership teams worked collaboratively with ministry contacts to address requirements, provide updates, and ensure alignment with provincial expectations and evolving sector priorities. These positive relationships are essential in supporting operational success and ensuring that the homes remain informed, prepared, and responsive to regulatory changes. The trust and credibility built through these relationships reflect the organization's commitment to transparency, accountability, and excellence. Page 7of54 Item Bobier Villa I Elgin Manor Terrace Lodge Cl Reviews 38 Ci's - 75.5% Abuse or Neglect; 13.5% Improper/ Incomplete Care; 8% Outbreaks; 3% Serious Injury MOLTC Updates Ontario announced province -wide funding to support the training and upskilling of nearly 3,000 long-term care staff $26 million investment to through the Supporting Professional Growth Fund and Living Classrooms programs. The initiative impacts staffing train frontline LTC staff recruitment, retention, and education opportunities across the sector. Ontario launched the Improving Dementia Care Program (IDCP), with plans to expand participation to nearly 50 homes Expansion of dementia care by 2027-28. The announcement also included funding for additional Behavioural Specialized Unit (BSU) beds and supports in LTC homes dementia -care staff training initiatives that will influence care practices across the LTC sector. The ministry confirmed that all long-term care homes must transition to the new interRAl Long -Term Care Facility Continued implementation of resident assessment system by April 1, 2026. The update affects assessment processes, documentation standards, interRAl LTCF assessment reporting, funding accuracy, and administrative operations in every LTC home in Ontario transition LTC Budget Updates Funding Envelope 2025-2026 Per Diem Rate Purpose / What It Covers Nursing & Personal Care (NPC) $112.63 Nursing staff, PSWs, direct resident care, medical and clinical supplies, wound care, continence products, equipment used in resident care Programs & Support Services (PSS) $13.16 Activation staff, therapy services, recreation programs, social work, restorative care, program supplies Nutritional Support (NS / Raw Food) $13.44 Raw food costs, supplements, nutritional products, therapeutic diets, condiments Other Accommodation (OA) $65.36 Housekeeping, laundry, administration, maintenance, utilities, dietary staffing, building operations Global Per Diem $7.94 Additional operational funding support applied across home operations Page 8of54 Total Per Diem Funding $212.53 per resident/day Combined provincial operational funding We are moving the policies to an on line platform. The platform will ensure the policies are easily accessible to staff and Homes departmental policy link them to education as well as the website. The policies were reviewed and revised during the last quarter of 2025. updates Contract Updates Agreements: LSAA: LSAA Schedule E - Annual Attestation was signed March 9, 2026 for all 3 homes. No outstanding items. IVISAA: MSAA For the County of Elgin was signed March 10, 2026. No outstanding items. Service Providers: The homes continue to work with a number of schools to support educational opportunities for students. This includes Students: but is not limited to: RN's, RPN's, PSW, business office, dietary management, physiotherapy and many more. Departmental highlights Administration: With the start of the new year the Homes worked diligently to evaluate all mandatory programs and to set out goals for the coming year, this includes the completion of our annual QIP The Homes focused on supporting Mental Health and wellness for staff and residents. For staff - A special group of staff from across all 3 homes continued and completed their work on Mental Health in the workplace — collaborating with the HR team to help develop a plan to support mental health and wellness for all Homes staff —TL held a "let kindness grow" week on Feb 23 — 27. For residents - Staff from all 3 homes were selected to participate in the Silver Meridian — Mental Health Recovery Care Certificate program running from Jan — May the program trained staff to be able to provide advanced care planning and support for residents in our homes living with complex mental health disorders. Nursing: TENA continent product switch over Skin and Wound -Designated skin care TENA continent product switch over was successfully completed. Overall leads to ensure consistency of wound was successfully completed. Overall satisfaction of staff and residents. assessments. Working through satisfaction of staff and residents. intermittent issues with the app. Page 9of54 Programs: Annual (proactive) compliance review was completed the report was delivered with no findings. RSV outbreak over. This resulted in a MOIL inspection and there were no findings related to IPAC management of the outbreak. Resident Council held a silent auction at the end of 2025 and raised over $900; they have started to use the proceeds to enhance the Home. They have just donated Artwork to each Home unit. Continence -Switched to TENA and transition went very well. Functional Continence and Bowel management program with Monthly audits by team members of Continence team and monthly team meetings. Elgin Manor completed a New Horizons for Seniors Grant which resulted in the completion of a New Multi Sensory Room Registered staff participated in education from the clinical pharmacist and skin and would from medline. Working on RNAO best practice. We successfully increased the number of champions on our team. The Recreation Department of Terrace Lodge spent Q1 strategic planning for the major holidays and special events of 2026. This was a time of reflection, analysis and in- depth discussion on what worked and did not work in 2025. Planning for this Q included Valentin's Day, St. Patrick's Day and Easter/Spring as well as all the therapeutic programs in-between. Departmental goals were also set, as a team, and outlined in the 2026 program evaluation. Page 10 of 54 Support Services: Bobier Villa is now paired with three local partners to provide intergenerational programs. Programs include children as young as 3 months old to young adults in their teens. Introduction of the MealSuite parent account and implementation of online meal ordering Family Council is growing through the use of increased communication and participant engagement The standardized menu was roled out in February across all 3 homes. This helped with food costs and production. Residents are pleased with the menu change. Behind the scenes we have also been working on re -vamping the volunteer recruitment process at Terrace Lodge and increasing the onboarding of volunteers to directly support programs with the home. We have seen an increase in volunteer presence and will continue to work at this. We are also supporting a high- school Co-op student who has been a great addition to the recreation team. Looking forward to Q2 we are planning for our annual car show, spring/summer market, and our fist ever Spring Music Recital in conjunction with June Elley Music Services We celebrated many special occasions here at Terrace Lodge during the first quarter and invited Residents to choose menu items they would enjoy for these events. One popular selection was Lobster Ravioli. We also sold tickets to family members so they could share a special meal with their loved ones. Page 11 of 54 Development of a shared master menu for all three homes Positive impact on the food budget resulting from the new menus The housekeeping departement worked on strong IPAC practices. The team is looking forward to bringing in summer students to help with staffing needs that increase over the summer months. The Dietary Department also received a wonderful monetary donation from the Auxiliary Ladies. This generous donation was used to purchase new equipment, including brand-new food scoops. These scoops are extremely important to meal service, as they help ensure all Residents receive the correct portion sizes. During the first quarter, the department introduced new laundry racks as well as a new microfiber wet mop process to improve efficiency and workflow. Project Updates Administration: Standardization job routines are being done across the departments. This will help the homes deliver consistent quality work throughout the homes. In addition, we are investigating the opportunity for master schedules. Nursing: The nursing team is working on the Pain and Palliative care clinical pathway implementation. This will improve resident care and ensure the homes are meeting best practice standards of care for our residents. The homes are working on removing bedrails as part of their RNAO best practices. They have made significant improvements in this area and will continue to work to become bedrail free homes. Programs: The homes are working on providing a wide variety of special events to bring in spring. They are actively seeking new innovative programs to meet the diverse needs of our residents. Engaging special events for residents and family will be planned throughout the coming months. The Day programs continue to work on maintaining their clients level of care while supporting families with time to care for themselves. Support Services: The homes are launching a new spring and summer menu. We are working with our dietary team to standardize practices and ensure mealsuite is utilized to it's full capacity. This will enhance our pleasurable dining program at the homes. Page 12 of 54 Terrace Lodge is bringing linen services in house. This will improve service and IPAC practices. Once this is completed we will consider the opportunity to expand this to the other 2 homes. Challenges & Emerging PCC has Opportunities Resident Council highlights Council reviewed both the Quality Residents Council continues to serve At the beginning on the year, Council Improvement Plan as well as the as a strong voice in determining promptly noted a dormant wasp nest Resident and Family Survey, allowing programs and services, actively in the main courtyard and with the for Resident Input and understanding. reviewing the program calendars. assistance of the Maintenance Program suggestions include: A talk Department the nest was removed on the Elgin County Rail System, choir within a day. engagements, basketball, trips to Mackie's and the St. Thomas Bingo Hall. The Council organized a Silent Auction Council stays informed about the Through Council's brainstorming at the of 2025, all the proceeds were Homes goals and priorities by regarding improving communication collected and the Council raised over reviewing and providing input to both opportunities between staff and $900. Council then organized thank the Quality Improvement Plan and the residents, staff directories specifically you letters to be sent out to all Resident Family Satisfaction Survey made for residents were created and individuals who donated an auction distributed at Council, with additional item. Out of the proceeds from the copies being made available in the auction Council donated new artwork Residents' Council binder and posted for each wing. on the Council board. Page 13 of 54 Council, through constructive suggestions, assisted with the implementation of the new meal suite program. Pointing out areas that they were finding challenging, for example not knowing what was in a specific casserole by the picture. Recommending a more descriptive ingredient list. Continued program input allowing Residents to lead their own leisure pursuits. Program suggestions include Movies and Treats, Bingo twice a week and continued live musical Events. Resident focused inquires are promptly addressed through a close working relationship with Nursing, Recreation, IPAC (Infection Prevention and Control) and Dietary team. For example, "Door Knockers" being audited and replaced where needed and requested, information and questions regarding outbreaks and masking requirement and concern regarding serving rotation in the Dining Room. Council reviewed the 2025 Resident and Family Satisfaction Survey results and were given the opportunity to give their feedback and suggestions towards the Quality Improvement Plan. Council reviewed and were given the I Council brainstormed the spiritual opportunity to view the New Multisensory Room. care offerings within the home with discussions including their feedback on Sunday morning devotionals and ideas for Pastoral leaders who may be able to visit the home on a monthly basis. Council sent a thank you card to a local school music class for their February performance. Page 14 of 54 Family Council highlights The Family Council was re-established following interest from a family member, and an initial meeting was successfully held, subsequent meetings have had no participants Meetings continue to be clearly advertised on the monthly calendar, and invitations are sent out monthly via email to all POAs who have provided their address. The Manager of Programs and Therapy also verbally informs family members during casual interactions. The goal of Family Council meetings is to support collaboration and communication. The Manager of Programs and Therapy will continue to encourage attendance. Council reviewed the 2025 Resident and Family Survey, many expressing the importance of filling out this survey. Council understands that this assists the Home in setting prioritises specifically identified by Residents and their families. Family Council brought a concern forward regarding the floor drain system, this was inspected and promptly repaired. Increased communication was a concern identified early in the year; Family communications are now sent monthly and Family Council invitations are sent one week prior the meeting. Council utilises meetings to stay informed about IPAC measure and the reasoning behind them, changes in staffing, Home projects that are in the plans for 2026(new phone system, fence repair and new blind for common areas) Family Council reviewed the 2025 Resident and Family Satisfaction Survey Results and were given the opportunity for discussion and feedback. This included suggestions around increased utilization and communication of/to volunteers. Council also suggested that there be an option added to next year's survey asking, "would you like to be contacted to discuss your survey." After a suggestion from Family Council, the Terrace Lodge Tuck Shop added milk and sugar free cookies to their offerings. After advocacy for the return of meal show plates in the Dining Rooms Family Council have been assured they are "coming soon." Council provided input for the Valentine's Day programming evaluations that included morning Flower Arranging and Valentine's Day Tea with Keven Gorman. All feedback was noted on the evaluation for future programming. Page 15 of 54 Review of programs and services, including Physiotherapy and Hairdressing. Council brought forward multiple work order related items resulting in repairs of running toilets, heating, water pressure, and flag replacement. Financial Performance Indicator (Units) YTD Remaining Year End Target (Budget) Actual Target (Budget) Forecast Target (Budget) Forecast Operating Revenue $7,832,942.00 $7,799,244.00 $31,331,768.00 $31,354,890.00 39164710 39154134 Wages/Benefits $6,624,066.00 $6,036,938.00 $28,988,056.00 $27,770,712.00 35612122 33807650 Operating Expense $1,005,892.00 $1,034,389.00 $4,023,471.00 $4,018,843.00 5029363 5053232 Capital Revenue 0 0 0 0 0 0 Capital Expense 254236 42482 1016977 1026325 1271213 1068807 Variance Discussion: The homes are working on recovering outstadning AR's. This process will take a period of time and significant effort. First Quarter the budget spending is controled to help create a cushion for the homes for the year. We have worked on reducing overtime giving us a faverable outcome. Wages and Benefits are coming in under due to work on reduction of over time. People Performance Indicator (Units) YTD Remaining Year End Target Actual Target Forecast Target Forecast # of Lieu hours 837.5 648.3 2572.5 2325 3430 3100 Turnover Rate 28.33% 7% 28.33% 28% 28% 28 # of Sick hours in the quarter 4666.67 16767.94 4666.67 5833.33 9333.33 22601.27 Page 16 of 54 # of Overtime hours paid 733.33 3570.26 733.33 1000.00 1466.67 4570.26 # of wsib claims 20.00 21 60.00 75.00 80.00 100.00 # of Short term leave of absence 20.00 24 60.00 75.00 80.00 100.00 # of Grievances 20.00 22 60.00 66.00 80.00 88.00 Variance Discussion: Currently Overtime is excessive in the Grievances are high. We have had some wsib claims are high due to outbreaks in homes. We are working on routines and issues with the call out platform the homes adaquate staffing plans to improve this resulting in staff not receiveing shifts area. they should have been awarded. This is being worked on. Internal Process Performance Indicator (Units) YTD Remaining Year End Target Actual Target Forecast Target Forecast # of MOL Infraction 1 2 1 1 1 3 # of Public Health Infraction 1 0 1 1 1 1 # of Fire Infractions 1 0 1 1 1 1 # of MOLTC Inspections 3 4 3 2 3 6 # of MOLTC Orders 0 0 0 0 0 0 # of CI's 35 39 35 39 35 78 Occupancy Rate 98.00% 99.17% 98.00% 99.00% 98.00% 198.17% Preferred Accommodation 60.00% 53.98% 60.00% 55.00% 60.00% 108.98% Basic Accommodation 40.00% 44.86% 40.00% 45.00% 40.00% 89.86% # of People on Waiting List 60 646 600 675 600 675 Page 17 of 54 Variance Discussion: The homes waitlist and occupancy is strong. The area of improvement is the 60/40 split. We are working on this to maximize the funding for the homes. The issue occurred during COVID and the homes are working on fixing it now. Customer Performance Indicator (Units) YTD Remaining Year End Target Actual Target Forecast Target Forecast # of outbreaks 3 4 3 6 3 6 # of res who have a pressure ulcer - recently worse 30 38 30 38 30 38 # of res who were transferred to the Emergency Dept 30 39 30 39 30 39 # of res on antipsychotics without diagnosis 15 16 15 16 15 16 Total of Arrears over 30 Days -$125,000 $-136,780.82 -$125,000 -$125,000 -$125,000 -$120,000 Variance Discussion: The homes are working on improving quality of care in the above areas. The quality teams review each resident outcome to identify opportunities for improvements. Page 18 of 54 Homes Successes: Bobier Villa Bobier Villa celebrated St Patrick's day by letting our creative side free. Laughter and fun were had by all as we created wreathes to decorate our hallways. Later that day we boarded our armchairs and traveled over the ocean to the Emerald Isle. Fitness is an important part of life at Bobier Villa we enjoy a variety of activities that keep us moving and feeling energized. In March we added some Latin flare and added Latin Chair dancing. New music and new moves got our heart rates up as we enjoyed this new activity. Pet Therapy can lower blood pressure, improve mood and provide a sense of comfort and we are fortunate at Bobier Villa to have one of the best furry staff members around. Duke our resident Pet Therapy dog is loved by all as he greets people with his wagging tail and cuddle demeanor. Page 19 of 54 Elgin Manor Winter has been a busy time at Elgin Manor, a variety of Activities have captivated both Resident and Family alike. Little Hobby Farms brought Joy and comfort to Elgin Manor through the calming presence of their friendly animals. Interacting with animals can spark happy memories, encourage conversation and increase the feeling of well-being. Little Hobby Farms always creates an uplifting experience that adds excitement to our day here at Elgin Manor. March 12t" our brand new Multi Sensory Room opened. This was made possible by a grant from the New Horizons for Seniors Program. The Multi Sensory Program utilizes sight, smell, sound and touch to create a calming environment that can be used to create a sence of calm or stimulat the sensens. Ireland came to Elgin Manor and we celebrated with fun Irish pictures and some beautiful Irish dancing. Residents and staff alike donned there green and enjoyed being Irish for a day. Page 20 of 54 Terrace Lodge The Residents of Terrace Lodge enjoyed an afternoon of Valentine's Day cookie decorating. Whether they came to tap into their creative side and practice the art of cookie decorating or just for the treat and conversation, all in attendance enjoyed. This is a program we offer seasonally that helps to get Residents in the holiday spirit and provides an opportunity for reminiscing about some of their own homemade treats and tradiations. St Patrick's Day Celebrations drew a crowd at Terrace Lodge and didn't disappoint. Residents dressed in all shades of green gathered in the Event Space to sing along to their favorite Irish Tunes with The Finlay's. Page 21 of 54 By Resident request we offered an Easter Bonnet program where Residents could create their very own. Each bonnet was uniquely beautiful in its own way and could be seen worn throughout the week. This program has already been requested to repeat, next year! Financial Implications: N/A Advancement of the Strategic Plan: This initiative supports the efficient operation of Elgin County's three long-term care homes by strengthening service delivery, enhancing resident outcomes, and promoting continuous quality improvement. It aligns with requirements of the Fixing Long -Term Care Act, ensuring the provision of safe, person -centred, and accountable care while maintaining compliance with all applicable legislative and regulatory standards. Local Municipal Partner Impact: N/A Communication Requirements: The Elgin County long-term care homes maintain strong communication with all stakeholders by fostering open, consistent, and transparent channels of information sharing among residents, families, staff, physicians, community partners, and governing bodies. Regular meetings, resident and family councils, staff updates, surveys, and timely reporting processes ensure that all parties are informed, engaged, and able to provide feedback. This commitment to effective communication strengthens trust, supports collaboration, and helps create a responsive environment focused on quality care and positive outcomes for residents. Conclusion: Overall, the first quarter of the year has been highly productive and successful for the Elgin County long-term care homes. Strong financial performance, proactive contract Page 22 of 54 management, collaborative labour relations, excellent resident care, positive ministry engagement, and focused leadership have all contributed to a solid and encouraging start to the year. These accomplishments reflect the resilience, expertise, and dedication of teams across Elgin County, all working together to achieve excellence in care and operations. As the organization moves into the next quarter, it does so from a position of strength, with clear momentum and confidence in its ability to continue delivering exceptional outcomes for residents, staff, and stakeholders. The progress made in the first quarter provides a strong platform for continued growth, innovation, and success throughout the remainder of the year. All of which is Respectfully Submitted Approved for Submission Joe Anne Holloway Blaine Parkin Director of Homes and Seniors Services Chief Administrative Officer Page 23 of 54 �'Ju_IIU° 1 ey Bobier Villa CQI Initiative Annual Report Page 24 of 54 MEMBERSHIP: DESIGNATED LEAD(S): Terri Benwell - Administrator Leezanne Young - Quality Improvement Coordinator Administrator Medical Director Manager of Resident Care Manager of Support Services Infection Prevention and Control Manager of Program Therapy Dietitian Pharmacist Physiotherapist Quality Improvement lead Personal Support Worker Nurses Resident Council Member Family Council Member QUALITY COMMITTEE PLANNING MEASURES: Our Continuous Quality Improvement meetings are combined with our Professional Advisory Committee (PAC) meetings. Meetings occur quarterly on the third Thursday of the month. Attendance in person is preferred, however, in the event that members cannot attend in person, a virtual option is available. In between quarterly CQI meetings Bobier Villa hosts monthly CQI subcommittee meetings. Information provided by (quarterly) CQI-PAC members is incorporated into discussions at the monthly meetings and to our program evaluations allowing the subcommittee meetings to build upon the discussion from the quarterly meetings. Our meetings are built upon our vision, mission and value statements: Mission: The County of Elgin Homes and Seniors Services are committed to creating a caring environment where residents and staff feel safe, respected and valued. Vision: Through Continuous Quality Improvement, using best practice initiatives, we will be influential leaders in the provision of person -centered care within the long-term care sector. When initiating change ideas Bobier Villa strives to meet the Residents rights by placing `Residents First' as per our Values. This is the highest priority at Bobier Villa and this acronym identifies the organizational values: Nurturi Teams Safety Page 25 of 54 PLANNING CYCLE AND PRIORITY SETTING To identify preliminary priorities an evaluation of the following occurs: • Inspection reports: Ministry of Long -Term Care, Ministry of Labour, Public Health, Fire Marshall, Joint Health and Safety • Complaints, Requests, Concerns and Input: Concern/Request forms, Resident Council input, Family Council input, Written complaints, Critical Incident reports. • Operational Analysis: Program Evaluations, Policy Review recommendations • Time Studies/Focused and Routine Audits • Public website reporting • Resident Quality Indicator review • Departmental Audits • Ongoing analysis of performance data over time available through CIHI; with areas indicating a decline in performance over time and/or where benchmarking against self identified peer organizations suggests improvement required • Mandated provincial improvement priorities Preliminary priorities are presented and discussed at various forums to validate priorities and to identify additional priorities that may have been missed. These forums include weekly leadership team meetings, monthly project management meetings, Resident Council, Family Council, Joint Health and Safety Committee, PAC-CQI team, CQI subcommittee meetings, staff meetings and Committee of Management. The process used is one of building, refining, and improving a project or initiative. Teams create and revise the process until they're satisfied with the end result. This process is a trial -and -error methodology that brings the project closer to its end goal but requires engagement and communication with various stakeholders along the way. Final review of the QIP is completed by the CQI team, approved by resident council then reported to the Committee of Management. The final QIP is submitted to Health Quality Ontario. APPROACH TO CQI (POLICIES, PROCEDURES AND PROTOCOLS) County of Elgin Homes policies, combined with practice standards, provide a baseline for staff in providing quality care and seances. We have an interdisciplinary CQI team, which includes resident and family advisors, that meet monthly, with subcommittees that report to the CQI team, as they work through the phases of the model to: 1. Diagnose/Analyze the Problem Teams use various QI methodologies to understand some of the root causes of the problem and identify opportunities for improvement. This work can include process mapping or value stream mapping, 5 Whys, fishbone. Also included in this work, is an analysis of relevant data and the completion of a gap analysis of the relevant RNAO Best Practice Guidelines. 2. Set Improvement Goals An improvement aim is identified once the teams have a grounded understanding of what is most important to the Resident. This aim will be used to evaluate the impact of the change ideas through implementation and sustainability. Page 26 of 54 At Bobier Villa improvement teams develop goals that are SMART goals: Specific, Measurable, Attainable, Relevant, Time -Bound. 3. Develop and Test Change Ideas With a better understanding of the current system, improvement teams identify various change ideas that progress towards meeting the goal. During this phase, teams will prioritize alignment with best practices when designing preliminary change ideas for testing. Plan -Do -Study -Act (PDSA) cycles are sometimes used to test change ideas through small tests of change. PDSA's provide an opportunity for teams to iteratively refine their change ideas and build confidence in the solution prior to implementation. Change ideas typically undergo several PDSA cycles before implementation. These changes are reflected in the project management minutes, team meeting minutes and communicated to staff via communication boards and huddles. 4. Implement and Sustain Improvement teams consider the following factors when developing a strong implementation/change management plan: • Outstanding work to be completed prior to implementation (e.g. final revisions to change ideas based on PDSA's, embedding changes into existing workflow, updating relevant policies and procedures, etc.) • Education required to support implementation, including key staff resources i.e. team leaders • Communication required to various stakeholders, before, during and after implementation which includes resident and family council, staff, committee of management At this stage, teams will also identify key project measures to determine if the changes implemented resulted in improvement. This includes the following types of measures: Outcome Process Balancing Measures what the team is Measures key activities, tasks, Measures other parts of the trying to achieve (the goal) processes implemented to system that could be achieve goal unintentionally impacted by changes 5. Process to communicate outcomes Communication strategies are tailored to the specific improvement initiative. These include, but are not limited to: • Posting on unit quality boards, in common areas and in staff lounges • Publishing stories and results on the website, on social media or via the newsletter • Direct email to staff and families and other stakeholders • Handouts and 1:1 communication with residents • Presentations at staff meetings, Resident Council, Family Council • Huddles at change of shift • SURGE Learning • Use of Champions to communicate directly with peers • RNAO BPSO Knowledge Exchange and engagement sessions The team ensures that regular reviews of the changes to ensure sustainability remains viable. This is typically conducted at the monthly CQI meetings and the project management meetings. Page 27 of 54 MODERATE ACTION: PROGRAM EVALUATIONS These are reviewed and updated quarterly at PAC-CQI. Medication Program: Goal to improve overall satisfaction with physician seances provided, maintain evidence -based practices and support the on -going education and development of clinical staff members. 2. Skin and Wound: Identify Residents at risk for skin breakdown & and promote early identification of wounds, assessment, and implementation of treatments to promote healing. This program ensures that staff have been provided with education and resources that support a skin friendly home and enables program members to develop action plans and specify audit needs for the annual program cycle. 3. Restraints & PASDS: Monitoring and auditing the application all PASD in the home; care plan the use of PASD& ensure the task/intervention is discontinued when no longer is needed; and continue education efforts to ensure all staff registered and PSW staff are appropriately informed of PASD use, definitions and best practices. 4. Continence: Provide education to staff regarding products and appropriate use; maintain auditing process for use and product assignment; provide training and knowledge regarding the continence program during initial orientation of new staff; and reduce the overall waste of incontinence products. 5. Falls: To ensure individualized toileting routines are implemented according to continence assessments; develop system so PSWs are aware of any medication changes as this factor does influence risk of falls and coincide with conditions that may increase injury with a fall; and Ensure Head Injury Routine being completed post unwitnessed fall or fall resulting in hitting head to ensure assessment being done for injury. 6. Responsive Behaviors: To ensure the needs of residents with responsive behaviors are met through use of BSO referrals upon admission where appropriate, implementation of the Snoezelen room following grant approval, and the on -going recruitment and support of new BSO staff members. 7. Restorative Care: To maintain and improve the overall independence of residents in the program, maintain audit completion to ensure all staff charting and documentation is being completed accurately and within a timely manner; and increase education and resources available to staff regarding restorative care. The Manager of Program and Therapy is the lead for the annual review, revisions, and distribution of the resident and family satisfaction surveys, serving as a liaison between the Continuous Quality Improvement (CQI) committee and the Resident and Family Council. Residents are provided an opportunity to review the survey and provide feedback on the questions prior to its formal distribution. The annual satisfaction survey is based on a calendar year rather than a fiscal year. This means the 2025 action plan was informed by 2024 data, while the current 2026 action plan is being developed using the results from the 2025 survey. The annual Resident and Family Satisfaction survey was completed from October 1st, 2025 to December 31st, 2025 via verbal, written and virtual channels. The 2025 Resident and Family Satisfaction survey saw participation from 13 respondents, expanding slightly from 9 respondents in 2024. Unlike the previous year where residents made up most respondents (66.67%), the 2025 survey saw a more balanced mix, with 46.15% completed by residents, 38.46% by family members, and 15.38% completed jointly. In a resounding perfect score for the home's reputation, 100% of respondents in both 2024 and 2025 stated they would recommend Bobier Villa to others. Page 28 of 54 The leadership team aims to provide blended learning opportunities for staff to engage with evidence - based research and further their skills, knowledge and confidence. These micro -modules will be presented by leadership members to the frontline teams via visual resources, electronic modules and communications, as well as verbal dictation from leadership or designates. Resident and Family Council will support the monitoring and implementation of our staff learning initiatives by providing their experience and knowledge of current practice, culture and outcomes of care via verbal or written discussion at regular Resident Council and Family Council Meetings. These insights will be transferred to the CQI-PAC Meetings and used to develop SMART goals and change frameworks as needed. KEY SATISFACTION HIGHLIGHTS INCLUDE: Nursing & Personal Care: Overall satisfaction with nursing and personal care services achieved a 100% positive rating, with 69.23% evaluating it as "Excellent" and 30.77% as "Satisfied". Home Cleanliness & Odour Control: The home achieved flawless marks in environmental maintenance, with 100% of respondents rating both resident room cleanliness and odour control as positive (84.62% Excellent; 15.38% Satisfied). Food & Nutrition Services: General satisfaction with food and nutrition sat at 100%, with 53.85% rating it "Excellent" and 46.15% "Satisfied". Staff Interaction: Residents felt highly respected, with 100% stating that dignity and privacy are respected (61.54% Excellent; 38.46% Satisfied) and 100% noting that staff address them by their preferred name. COMMUNICATION AND ACTION PLANNING The Manager of Programs and Therapy presented these 2025 results to the Resident Council at the February 26th, 2026 meeting, initiating the development of the formal action plan in March 2026. While discussion regarding priority areas and possible actions for improvement were minimal, their discussion did highlight improvement opportunities for staff regarding their approach to care and orientation for frontline staff. Results were also shared with the Family Council during their March 13th, 2026 meeting to gather input for the 2026 Quality Improvement Plan. Additionally, the management team reviewed the survey data during the CQI February 11th committee meeting and PAC-CQI March 12th, 2026. Department -specific information has been disseminated to individual leads to ensure targeted improvements are integrated into daily operations. ACTION TAKEN TO IMPROVE RESULTS: In Q3 and Q4 the CQI team reviewed the areas of focus and formatted a plan to address the areas for improvement that were identified in the previous year's satisfaction survey and in alignment with the proposed 2026 survey goals. Opportunities for improvement were incorporated into the annual program implementation plans as well as the Health Quality Ontario, Quality Improvement Plan, where applicable. The Manager of Program and Therapy or the delegate(s) continue to provide updates at the council meetings. Survey Focus 2024 Survey 2025 Survey Implementation Actions & Feedback Outcomes Outcomes Notes How well staff 88.89% 100% Yes / 2024 Feedback: Comment noted that staff listen to you / Satisfied/Excellent Positive (38.46% "look at me but don't hear." Having a (11.11% Excellent; 61.54% voice Dissatisfied) Satisfied) Page 29 of 54 2025 Status: Greatly improved to 100% positive perception. One respondent noted staff are occasionally too busy but promise to return shortly. 100% 61.54% 2025 Status: Shift in metrics due to a high Call bell Satisfied/Excellent Satisfied/Excellent volume of "Unsure" responses. Multiple response (0% Dissatisfied / (38.46% Unsure; comments indicated they "don't really use time Unsure) ° 0 /o Dissatisfied) it," though one caregiver noted it "sometimes takes too long." Nametags: 100% 100% across all Positive (76.92% Exc) fields 2024 Feedback: Discrepancies noted with understanding new staff arrival Staff wear a (Nametags announcements. name tag, Introduction: introduce 11.11 % Exc / 92.31 % Positive themselves 88.89% Sat; (69.23% Exc; 7.69% 2025 Status: Performance remains and explain roles Introduction/Role: Dissatisfied) incredibly high. Daily leadership walk - rounds will continue to monitor visual 33.33% Exc / identification and introduction compliance. 66.67% Sat) Explain Role: 100% Positive 61.54% Exc Care Planning Satisfaction: 2024 Feedback: Qualitative comments 69.23% Input mentioned input is only utilized Participation Utilized (30.77% "sometimes." Unsure) in plan of 100% Input care / input Important 2025 Status: Zero dissatisfaction reported utilized Planning across both years. "Unsure" marks Satisfaction: highlight an opportunity to better clarify 76.92% (23.08% care conference structures to families. Unsure) Food Temp: 88.88% Positive Food Temp: 84.61% Positive 2024 Feedback: Noted concerns that potatoes tasted "from a box" and choice Pleasurable was tough. Dining:Presentation: 88.88% Positive Presentation: Temperature, 84.61% Positive presentation & overall 2025 Status: Overall satisfaction with food satisfaction Overall Diet: rose to a perfect 100%. Positive feedback Overall Diet: 100% Positive highlighted a good variety of meals 77.77% Positive (53.85% Exc; accommodating picky eaters. (22.22% 46.15% Sat) Dissatisfied) FRONTLINE SAFETY AND CLINICAL CAPACITY BUILDING Bobier Villa successfully prioritized occupational safety and advanced clinical training during this performance cycle by introducing a dedicated Education Coordinator role in July 2025 to oversee professional growth. Under this expanded leadership framework, the home executed facility -wide Arjo Lift Training for its frontline clinical teams. This specialized training was completely facilitated in -person, a Page 30 of 54 method that substantially enhanced staff confidence and minimized mechanical workplace risks during resident transfers. Concurrently, the home launched a comprehensive InterRAI education initiative tailored specifically for Personal Support Workers (PSWs), registered nursing staff, and the recreation department to improve accurate internal data capture. To further alleviate frontline administrative fiction during demanding operational periods, the home streamlined its PPE storage systems and introduced specialized electronic auditing tools to reduce documentation burdens during infectious outbreaks. These technical improvements were balanced with community -building initiatives like "Infection Control Week" celebrations, which blended interactive educational games with direct staff appreciation rewards to keep morale high. EQUITY, DIVERSITY, AND INCLUSION WORKFORCE EDUCATION To cultivate a deeply inclusive environment, Bobier Villa undertook an expansive workforce development initiative focused on equity, diversity, inclusion (EDI), and anti -racism education across the 2025-2026 fiscal cycle. In September 2025, specialized 2SLGBTQI+ seniors' education modules were systematically assigned to all staff members within the facility. To ensure comprehensive coverage, mandatory training on workplace harassment, discrimination, civility, and respect was paired with targeted mental health and wellness sessions provided in partnership with the Canadian Mental Health Association. Following this localized push, mandatory LGBTQ+ education was formalized for the entire staff in late 2025 to solidify a safe, welcoming home culture for both residents and team members. This workforce initiative was reinforced by upgrading the facility's orientation and onboarding workflows through the integration of the CLRI preceptor program. These parallel efforts successfully culminated in a 100% staff completion rate for relevant EDI and anti -racism modules heading into the upcoming operational period. CLINICAL PATHWAYS ASSESSMENT IMPLEMENTATION The Clinical Pathways for Falls and Pain assessments officially went live on November 27th, marking a significant shift in our clinical framework. The initial rollout presented several implementation challenges, as staff worked to navigate changes in the admission process and adapt to more rigorous documentation standards. Despite these early hurdles, the initiative gained steady momentum, resulting in high levels of consistency and compliance throughout the final quarter of the report (January 2026 — March 31, 2026). This standardized approach has already begun to improve the reliability of resident data and ensure more responsive care planning. The Bobier Villa CQI committee develops and submits a Quality Improvement Plan (QIP) to Health Quality Ontario annually. The QIP includes a progress report which captures the progress/lessons learned while the narrative summarizes the CQI journey in the prior year's QIP. The workplan outlines the aims, measures and change ideas for the 2026/2027 QIP. FOCUSED ACTION: 1. Access and Flow • Reduce the rate of potentially avoidable emergency departments visits to or below the provincial benchmark of 21.9 through: o Utilization of the standard RNAO Nursing Advantage Canada, Clinical Pathways assessments (Admission, Fall Prevention, Pain assessment, Palliative) o Continue our partnerships with local hospital, Facilities Operator Group (FOG) and pharmacy to continue work on "Transitions in Care" between hospital and long-term care o Development of processes to support the utilization of Nurse Led Outreach Team (NLOT), which will facilitate the application of nursing knowledge, skills and judgement in resident care to decrease avoidable ED visits. Page 31 of 54 o Maintain use of Comfort Care Rounds for residents identified as being high risk for falls or having a precarious health condition o Audit the completion of medication reconciliation within 24 hours of admission and upon return from hospital to further support ED visit reduction and application of RNAO Transitions in Care guidelines. 2. Equitable • Achieve 100 percentage of staff (all levels) who have completed relevant equity, diversity, inclusion and anti -racism education through: o Development and implementation of a DEI policy specific to long-term care home resident care and seances utilizing the CLRI diversity tool kit o Maintain the enhanced orientation and onboarding process utilizing CLRI preceptor program; ensuring the process and resources remain up to date. o Develop and implement blended learning modules and micro -modules to increase staff engagement and optimize knowledge retention. In April of 2026 these improvements and applicable measures will be reviewed with resident and family councils, at which time their feedback and participation in upcoming efforts will be recorded and applied to our efforts. Further application of RNAO's best practice guidelines as they pertain to Transitions in Care will enhance our person & family centered care practices will contributing to the reduction of ED visits. Bobier Villa will further the impact of their quality initiatives by using blended learning formats and the application of adult learning models to enhance the cultural awareness and knowledge of our staff. This action in collaboration with the implementation of Clinical Pathways — Palliative & End of Life tools will further contribute to the quality of life and care service provision within our home. Page 32 of 54 CONTACT & ARCHIVE LINK For further information please refer to the Bobier Villa QIP progress report, narrative and workplan. The QIP is available on the County of Elgin Homes website https://www.elaincounty.ca/elain-county-lona- term-care-homes/ and documents posted on the QIP board located within the Home. The progress report details the action taken and the outcomes of the actions for the 2026/2027 QIP. X Joe Anne Hollowa ............................................................................................................................................................................................................ 2026 Director of Senior Services, Elgin County X Terri Benwell ......................................................................................................................................................................... May 22 2026 Home Administrator — Bobier Villa, Elgin County X Leezanne Young ........................................................................................................................................................................................... 222026 Quality Improvement Coordinator, Elgin County Mav 22 Date of Review/ Approval Date of Review/ Approval May Date of Review/ Approval Page 33 of 54 �'Ju_IIU° 1 ey Elgin Manor CQI Initiative Annual Report Page 34 of 54 MEMBERSHIP: DESIGNATED LEAD(S): Terri Benwell - Administrator Leezanne Young - Quality Improvement Coordinator Administrator Medical Director Manager of Resident Care Resident Care Coordinator Manager of Support Services Infection Prevention and Control Manager of Program Therapy Dietitian Pharmacist Physiotherapist Quality Improvement lead Personal Support Worker Nurses Resident Council Member Family Council Member QUALITY COMMITTEE PLANNING MEASURES: Our Continuous Quality Improvement meetings are combined with our Professional Advisory Committee (PAC) meetings. Meetings occur quarterly on the third Thursday of the month. Attendance in person is preferred, however, in the event that members cannot attend in person, a virtual option is available. In between quarterly CQI meetings Elgin Manor hosts monthly CQI subcommittee meetings. Information provided by (quarterly) CQI-PAC members is incorporated into discussions at the monthly meetings and to our program evaluations allowing the subcommittee meetings to build upon the discussion from the quarterly meetings. Our meetings are built upon our vision, mission and value statements: Mission: The County of Elgin Homes and Seniors Services are committed to creating a caring environment where residents and staff feel safe, respected and valued. Vision: Through Continuous Quality Improvement, using best practice initiatives, we will be influential leaders in the provision of person -centered care within the long-term care sector. When initiating change ideas Elgin Manor strives to meet the Residents rights by placing `Residents First' as per our Values. This is the highest priority at Elgin Manor and this acronym identifies the organizational values: Page 35 of 54 PLANNING CYCLE AND PRIORITY SETTING To identify preliminary priorities an evaluation of the following occurs: • Inspection reports: Ministry of Long -Term Care, Ministry of Labour, Public Health, Fire Marshall, Joint Health and Safety • Complaints, Requests, Concerns and Input: Concern/Request forms, Resident Council input, Family Council input, Written complaints, Critical Incident reports. • Operational Analysis: Program Evaluations, Policy Review recommendations • Time Studies/Focused and Routine Audits • Public website reporting • Resident Quality Indicator review • Departmental Audits • Ongoing analysis of performance data over time available through CIHI; with areas indicating a decline in performance over time and/or where benchmarking against self identified peer organizations suggests improvement required • Mandated provincial improvement priorities Preliminary priorities are presented and discussed at various forums to validate priorities and to identify additional priorities that may have been missed. These forums include weekly leadership team meetings, monthly project management meetings, Resident Council, Family Council, Joint Health and Safety Committee, PAC-CQI team, CQI subcommittee meetings, staff meetings and Committee of Management. The process used is one of building, refining, and improving a project or initiative. Teams create and revise the process until they're satisfied with the end result. This process is a trial -and -error methodology that brings the project closer to its end goal but requires engagement and communication with various stakeholders along the way. Final review of the QIP is completed by the CQI team, approved by resident council then reported to the Committee of Management. The final QIP is submitted to Health Quality Ontario. APPROACH TO CQI (POLICIES, PROCEDURES AND PROTOCOLS) County of Elgin Homes policies, combined with practice standards, provide a baseline for staff in providing quality care and services. We have an interdisciplinary CQI team, which includes resident and family advisors, that meet monthly, with subcommittees that report to the CQI team, as they work through the phases of the model to: 1. Diagnose/Analyze the Problem Teams use various QI methodologies to understand some of the root causes of the problem and identify opportunities for improvement. This work can include process mapping or value stream mapping, 5 Whys, fishbone. Also included in this work, is an analysis of relevant data and the completion of a gap analysis of the relevant RNAO Best Practice Guidelines. 2. Set Improvement Goals An improvement aim is identified once the teams have a grounded understanding of what is most important to the Resident. This aim will be used to evaluate the impact of the change ideas through implementation and sustainability. At Elgin Manor improvement teams develop goals that are SMART goals: Specific, Measurable, Attainable, Relevant, Time -Bound. Page 36 of 54 3. Develop and Test Change Ideas With a better understanding of the current system, improvement teams identify various change ideas that progress towards meeting the goal. During this phase, teams will prioritize alignment with best practices when designing preliminary change ideas for testing. Plan -Do -Study -Act (PDSA) cycles are sometimes used to test change ideas through small tests of change.PDSA's provide an opportunity for teams to iteratively refine their change ideas and build confidence in the solution prior to implementation. Change ideas typically undergo several PDSA cycles before implementation. These changes are reflected in the project management minutes, team meeting minutes and communicated to staff via communication boards and huddles. 4. Implement and Sustain Improvement teams consider the following factors when developing a strong implementation/change management plan: • Outstanding work to be completed prior to implementation (e.g. final revisions to change ideas based on PDSA's, embedding changes into existing workflow, updating relevant policies and procedures, etc.) • Education required to support implementation, including key staff resources i.e. team leaders • Communication required to various stakeholders, before, during and after implementation which includes resident and family council, staff, committee of management At this stage, teams will also identify key project measures to determine if the changes implemented resulted in improvement. This includes the following types of measures: Outcome Process Balancing Measures what the team is Measures key activities, tasks, Measures other parts of the trying to achieve (the goal) processes implemented to system that could be achieve goal unintentionally impacted by changes 5. Process to communicate outcomes Communication strategies are tailored to the specific improvement initiative. These include, but are not limited to: • Posting on unit quality boards, in common areas and in staff lounges • Publishing stories and results on the website, on social media or via the newsletter • Direct email to staff and families and other stakeholders • Handouts and 1:1 communication with residents • Presentations at staff meetings, Resident Council, Family Council • Huddles at change of shift • SURGE Learning • Use of Champions to communicate directly with peers • RNAO BPSO Knowledge Exchange and engagement sessions • Continuous Quality Improvement Subcommittee Meetings & Professional Advisory Committee Meetings The team ensures that regular reviews of the changes to ensure sustainability remains viable. This is typically conducted at the monthly CQI meetings and the project management meetings. Page 37 of 54 MODERATE ACTION: PROGRAM EVALUATIONS These are reviewed and updated quarterly at PAC-CQI. 1. Medication Program: Goal to improve overall satisfaction with physician seances provided, maintain evidence -based practices and support the on -going education and development of clinical staff members. 2. Skin and Wound: Identify Residents at risk for skin breakdown & and promote early identification of wounds, assessment, and implementation of treatments to promote healing. This program ensures that staff have been provided with education and resources that support a skin friendly home and enables program members to develop action plans and specify audit needs for the annual program cycle. 3. Restraints & PASDS: Monitoring and auditing the application all PASD in the home; care plan the use of PASD& ensure the task/intervention is discontinued when no longer is needed; and continue education efforts to ensure all staff registered and PSW staff are appropriately informed of PASD use, definitions and best practices. 4. Continence: Provide education to staff regarding products and appropriate use; maintain auditing process for use and product assignment; provide training and knowledge regarding the continence program during initial orientation of new staff; and reduce the overall waste of incontinence products. 5. Falls: To ensure individualized toileting routines are implemented according to continence assessments; develop system so PSWs are aware of any medication changes as this factor does influence risk of falls and coincide with conditions that may increase injury with a fall; and Ensure Head Injury Routine being completed post unwitnessed fall or fall resulting in hitting head to ensure assessment being done for injury. 6. Responsive Behaviors: To ensure the needs of residents with responsive behaviors are met through use of BSO referrals upon admission where appropriate, implementation of the Snoezelen room following grant approval, and the on -going recruitment and support of new BSO staff members. 7. Restorative Care: To maintain and improve the overall independence of residents in the program, maintain audit completion to ensure all staff charting and documentation is being completed accurately and within a timely manner; and increase education and resources available to staff regarding restorative care. The Manager of Program and Therapy is the lead of the annual review, revisions, and distribution of the resident and family satisfaction surveys, serving as a liaison between the Continuous Quality Improvement (CQI) committee and the Resident and Family Council. Residents are provided an opportunity to review the survey and provide feedback on the questions prior to its formal distribution. The annual satisfaction survey is based on a calendar year rather than a fiscal year. This means the 2025 action plan was informed by 2024 data, while the current 2026 action plan is being developed using the results from the 2025 survey. The annual Resident and Family Satisfaction survey was completed from October 1st, 2025 to December 31st, 2025 via verbal, written and virtual channels and saw participation from 29 respondents, the vast majority of whom (93.10%) were family members or loved ones. In a resounding perfect score for the home's reputation, 100% of respondents stated they would recommend Elgin Manor to others. These results were shared with staff leads at a CQI-PAC monthly meeting on February — 2026. Results were also reviewed by department leadership to share verbally with frontline teams. The Manager of Programs and Therapy presented these 2025 results to the Resident Council at the February 26th 2026 meeting, initiating the development of the formal action plan in March 2026. While Page 38 of 54 discussion regarding priority areas and possible actions for improvement were minimal, their discussion did highlight improvement opportunities for staff regarding their approach to care and orientation for frontline staff. The leadership team aims to provide blended learning opportunities for staff to engage with evidence -based research and further their skills, knowledge and confidence. These micro -modules will be presented by leadership members to the frontline teams via visual resources, electronic modules and communications, as well as verbal dictation from leadership or designates. Resident and Family Council will support the monitoring and implementation of our staff learning initiatives by providing their experience and knowledge of current practice, culture and outcomes of care via verbal or written discussion at regular Resident Council and Family Council Meetings. These insights will be transferred to the CQI-PAC Meetings and used to develop SMART goals and change frameworks as needed. Results were also shared with the Family Council during their March 2026 meeting to gather input for the 2026 Quality Improvement Plan. Department -specific information has been disseminated to individual leads to ensure targeted improvements are integrated into daily operations. KEY SATISFACTION HIGHLIGHTS INCLUDE: 1. Nursing & Personal Care: Achieved a 100% satisfaction rating, with 58.62% of respondents rating services as "Excellent" and 41.38% as "Satisfied". 2. Cleanliness: 100% of respondents were satisfied with the cleanliness of the home and resident rooms (58.62% Excellent; 41.38% Satisfied). 3. Recreation Services: Earned a 96.55% satisfaction rating regarding overall recreation programming. 4. Food & Nutrition: Maintained a 93.11% satisfaction rating, with 48.28% rating the service as "Excellent". 5. Communication: 96.56% of respondents felt they had a voice and were listened to by staff. COMMUNICATION AND ACTION PLANNING The Manager of Programs and Therapy presented these 2025 results to the Resident Council at the February 26th 2026 meeting, initiating the development of the formal action plan in March 2026. Results were also shared with the Family Council during their March 13th 2026 meeting to gather input for the 2026 Quality Improvement Plan. Additionally, the management team reviewed the survey data during CQI February 11th committee meeting and PAC-CQI March 12th 2026. Department -specific information has been disseminated to individual leads to ensure targeted improvements are integrated into daily operations. ACTION TAKEN TO IMPROVE RESULTS: In Q3 and Q4 the CQI team reviewed the areas of focus and formatted a plan to address the areas for improvement that were identified in the previous year's satisfaction survey and in alignment with the proposed 2026 survey goals. Opportunities for improvement were incorporated into the annual program implementation plans as well as the Health Quality Ontario, Quality Improvement Plan, where applicable. The Manager of Program and Therapy or the delegate(s) continue to provide updates at the council meetings. 2024 2025 Implementation Actions Survey focus Survey Survey Outcomes Outcomes How well staff 92% 57.69% January -December 2025: Incorporated listen to you Very Satisfied / this into the redevelopment training: ensure Yes that resident rights to choose are respected and documented appropriately. Page 39 of 54 42.31% Unsure January - March 2026: With support of RNAO BPSO Lead, the home completed an opportunity analysis for Palliative, End of Life and Transitions in Care. All discussions were able to identify needs and provide potential change actions to improve resident choice and agency in care. - Efforts in this area will continue for the 2026 year by leveraging RNAO best practice guidelines, Champions Training and new approaches to knowledge sharing and staff training (blended learning). Annual education completed for all staff in our home via Surge Learning platform. Call bell 71% 51.86% Ongoing challenges such as the response time -Excellent/ implementation of Clinical Pathways has Satisfied increased staff workload, especially on days with new admissions, and thus further impacted team culture. - Engagement with staff and 44.44% management level leadership will be a continued focus in 2026 with -Unsure particular focus on education and training. Ongoing audits of call bells when concerns identified and follow up as appropriate. Staff wear a 89.65% 93.1 % Ongoing: Managers conducted name tag name tag, 96.56% (Nametags) audits through the year during morning and introduce afternoon rounds on the floor through 1:1 themselves 100% verbal reminders. Managers also and explain Separated into 3 86.2% communicated need for nametag and their roles proper introductions from staff at questions on the (Introduce) departmental meetings and huddles as 2024 survey well. Micro -modules are being developed to 89.66% provide further training on the floor with staff. (Explain role / action) Participation in 80.77% 61.54% April2025: the home continued the plan of care Very Satisfied/ implementation of InterRAI to provide better Satisfied data and evaluate/ meet specific resident needs more accurately. Family Council meetings also increased care planning 38.46% participation with a notable inquiry regarding staff education and training for Unsure lifts; led to administrative audit and review of lift trainer capacity in the home. - With the upcoming 2026 cycle this should increase as we implement RNAO best practice guidelines for Page 40 of 54 palliative, EoL, and transitional care. Pleasurable 60% 48.28% The home completed a major flooring Dining Excellent/ project in the dining room in April 2025, Temperature Satisfied coordinating the work to minimize disruption for residents. (Note: 0% Attractive meal dissatisfied, most Following resident feedback via the presentation responses were Council, the home explored the installation NA or `Unsure') of sheer curtains in common areas and rooms to improve lighting and atmosphere Overall while maintaining privacy. Satisfaction In the fall of 2025, the home planned the with program 62 08% implementation of "MealSuite" digital menu seances boards and production software to better communicate daily meal choices to 62.07% residents and families while improving the accuracy and management of services. Themed Meals & Menus for 2025: April: An 80s-themed meal featuring traditional comfort foods like meatloaf and chicken pot pie. Overall: May: A Cinco de Mayo celebration with a 93.11 % taco casserole menu. June: A special Father's Day lunch was hosted for residents and 25 guests, alongside resident and staff appreciation BBQs. Fall Themes: Later in the year, the home hosted "Talk Like a Pirate Day' with a seafood-themed menu, "Ukrainian Day," and a "Country Hoedown NEW HORIZONS FOR SENIORS PROGRAM: MULTISENSORY ROOM The Programs & Therapy department lead an exciting project to eenhance existing recreational and therapeutic services/spaces within our home for residents that may be exhibiting responsive behaviors, and co -residents that may be impacted by another resident's responsive behaviors. In collaboration with the internal Behavioral Support of Ontario (BSO) team, it has been identified that having a "space/multi- sensory room" situated in a central and accessible location of the Home benefits all residents and seniors living with dementia as a non -pharmacological intervention and, as part of a person -centered plan of care. This was initiated in April of 2025 and saw significant progress in August of 2025. On August 8th, the project planning team at Elgin Manor noted the camera and call bell had been installed with final touches such as painting being completed. This was accompanied by various other `house cleaning' items to improve our residents home environment such as blind replacements, courtyard landscaping, and the initiation of Ballard replacement. Leading into the end of our reporting period, the multisensory room was completed in March of 2026. It has since become a favorite for many residents, their families and our staff as they support improved quality of life. Page 41 of 54 BSO- EDUCATIONAL DEVELOPMENT OPPORTUNITIES Throughout the year, the home offered several educational opportunities to enhance staff competency, including training on Comfort Rounding and specialized webinars such as "Supporting the Sexual Health of People with Dementia" via BrainXchange. Intensive clinical sessions were also scheduled, featuring BSO Foundations, Gentle Persuasive Approaches (GPA), and U-First training. While these resources were consistently made available, participation rates remained varied, with some programs seeing limited completion. This highlights an ongoing objective to better align staff scheduling with available professional development sessions. CLINICAL PATHWAYS: SCREENING ASSESSMENT IMPLEMENTATION The Clinical Pathways for Falls and Pain assessments officially went live on November 27th, marking a significant shift in our clinical framework. The initial rollout presented several implementation challenges, as staff worked to navigate changes in the admission process and adapt to more rigorous documentation standards. Despite these early hurdles, the initiative gained steady momentum, resulting in high levels of consistency and compliance throughout the final quarter of the report (January 2026 — March 31, 2026). This standardized approach has already begun to improve the reliability of resident data and ensure more responsive care planning. The Elgin Manor CQI committee develops and submits a Quality Improvement Plan (QIP) to Health Quality Ontario annually. The QIP includes a progress report which captures the progress/lessons learned while the narrative summarizes the CQI journey in the prior year's QIP. The workplan outlines the aims, measures and change ideas for the 2026/2027 QIP. FOCUSED ACTION: 1. Access and Flow • Reduce the rate of potentially avoidable emergency departments visits to or below the provincial benchmark of 21.9 through: o Utilization of the standard RNAO Nursing Advantage Canada, Clinical Pathways assessments (Admission, Fall Prevention, Pain assessment, Palliative) o Continue our partnerships with local hospital, Facilities Operator Group (FOG) and pharmacy to continue work on "Transitions in Care" between hospital and long-term care o Development of processes to support the utilization of Nurse Led Outreach Team (NLOT), which will facilitate the application of nursing knowledge, skills and judgement in resident care to decrease avoidable ED visits. o Maintain use of Comfort Care Rounds for residents identified as being high risk for falls or having a precarious health condition o Audit the completion of medication reconciliation within 24 hours of admission and upon return from hospital to further support ED visit reduction and application of RNAO Transitions in Care guidelines. 2. Equitable Achieve 100 percentage of staff (all levels) who have completed relevant equity, diversity, inclusion and anti -racism education through: o Development and implementation of a DEI policy specific to long-term care home resident care and seances utilizing the CLRI diversity tool kit Page 42 of 54 o Maintain the enhanced orientation and onboarding process utilizing CLRI preceptor program; ensuring the process and resources remain up to date. o Develop and implement blended learning modules and micro -modules to increase staff engagement and optimize knowledge retention. In April of 2026 these improvements and applicable measures will be reviewed with resident and family councils, at which time their feedback and participation in upcoming efforts will be recorded and applied to our efforts. Further application of RNAO's best practice guidelines as they pertain to Transitions in Care will enhance our person & family centered care practices will contributing to the reduction of ED visits. Elgin Manor will further the impact of their quality initiatives by using blended learning formats and the application of adult learning models to enhance the cultural awareness and knowledge of our staff. This action in collaboration with the implementation of Clinical Pathways — Palliative & End of Life tools will further contribute to the quality of life and care service provision within our home. CONTACT & ARCHIVE LINK For further information please refer to the Elgin Manor QIP progress report, narrative and workplan. The QIP is available on the County of Elgin Homes website https://www.elaincounty.ca/elain-county-lona- term-care-homes/ and documents posted on the QIP board located within the Home. The progress report details the action taken and the outcomes of the actions for the 2026/2027 QIP. X Joe Anne Holloway ....................................................................................................................................................................................................................................................................................... 2026 Director of Senior Services, Elgin County X Terri Benwell ......................................................................................................................................................................... May 22 2026 Home Administrator — Elgin Manor, Elgin County X Leezanne Young ........................................................................................................................................................................................... 222026 May 22 ....................................................................................................................................................................................... Date of Review/ Approval Date of Review/ Approval May Page 43 of 54 Quality Improvement Coordinator, Elgin County Date of Review/ Approval Page 44 of 54 Terrace Lodge CQI Initiative Annual Report Page 45 of 54 MEMBERSHIP: DESIGNATED LEAD(S): Ashley Temple - Administrator Leezanne Young - Quality Improvement Coordinator Administrator Medical Director Manager of Resident Care Resident Care Coordinator Manager of Support Services Infection Prevention and Control Manager of Program Therapy Dietitian Pharmacist Physiotherapist Quality Improvement lead Personal Support Worker Nurses Resident Council Member Family Council Member QUALITY COMMITTEE PLANNING MEASURES: Our Continuous Quality Improvement meetings are combined with our Professional Advisory Committee (PAC) meetings. Meetings occur quarterly on the third Thursday of the month. Attendance in person is preferred, however, in the event that members cannot attend in person, a virtual option is available. In between quarterly CQI meetings Terrace Lodge hosts monthly CQI subcommittee meetings. Information provided by (quarterly) CQI-PAC members is incorporated into discussions at the monthly meetings and to our program evaluations allowing the subcommittee meetings to build upon the discussion from the quarterly meetings. Our meetings are built upon our vision, mission and value statements: Mission: The County of Elgin Homes and Seniors Services are committed to creating a caring environment where residents and staff feel safe, respected and valued. Vision: Through Continuous Quality Improvement, using best practice initiatives, we will be influential leaders in the provision of person -centered care within the long-term care sector. When initiating change ideas Terrace Ldoge strives to meet the Residents rights by placing `Residents First' as per our Values. This is the highest priority at Terrace Lodge and this acronym identifies the organizational values: Page 46 of 54 PLANNING CYCLE AND PRIORITY SETTING To identify preliminary priorities an evaluation of the following occurs: • Inspection reports: Ministry of Long -Term Care, Ministry of Labour, Public Health, Fire Marshall, Joint Health and Safety • Complaints, Requests, Concerns and Input: Concern/Request forms, Resident Council input, Family Council input, Written complaints, Critical Incident reports. • Operational Analysis: Program Evaluations, Policy Review recommendations • Time Studies/Focused and Routine Audits • Public website reporting • Resident Quality Indicator review • Departmental Audits • Ongoing analysis of performance data over time available through CIHI; with areas indicating a decline in performance over time and/or where benchmarking against self identified peer organizations suggests improvement required • Mandated provincial improvement priorities Preliminary priorities are presented and discussed at various forums to validate priorities and to identify additional priorities that may have been missed. These forums include weekly leadership team meetings, monthly project management meetings, Resident Council, Family Council, Joint Health and Safety Committee, PAC-CQI team, CQI subcommittee meetings, staff meetings and Committee of Management. The process used is one of building, refining, and improving a project or initiative. Teams create and revise the process until they're satisfied with the end result. This process is a trial -and -error methodology that brings the project closer to its end goal but requires engagement and communication with various stakeholders along the way. Final review of the QIP is completed by the CQI team, approved by resident council then reported to the Committee of Management. The final QIP is submitted to Health Quality Ontario. APPROACH TO CQI (POLICIES, PROCEDURES AND PROTOCOLS) County of Elgin Homes policies, combined with practice standards, provide a baseline for staff in providing quality care and services. We have an interdisciplinary CQI team, which includes resident and family advisors, that meet monthly, with subcommittees that report to the CQI team, as they work through the phases of the model to: 1. Diagnose/Analyze the Problem Teams use various QI methodologies to understand some of the root causes of the problem and identify opportunities for improvement. This work can include process mapping or value stream mapping, 5 Whys, fishbone. Also included in this work, is an analysis of relevant data and the completion of a gap analysis of the relevant RNAO Best Practice Guidelines. 2. Set Improvement Goals An improvement aim is identified once the teams have a grounded understanding of what is most important to the Resident. This aim will be used to evaluate the impact of the change ideas through implementation and sustainability .At Terrace Lodge, improvement teams develop goals that are SMART goals: Specific, Measurable, Attainable, Relevant, Time -Bound. Page 47 of 54 3. Develop and Test Change Ideas With a better understanding of the current system, improvement teams identify various change ideas that progress towards meeting the goal. During this phase, teams will prioritize alignment with best practices when designing preliminary change ideas for testing. Plan -Do -Study -Act (PDSA) cycles are sometimes used to test change ideas through small tests of change. PDSA's provide an opportunity for teams to iteratively refine their change ideas and build confidence in the solution prior to implementation. Change ideas typically undergo several PDSA cycles before implementation. These changes are reflected in the project management minutes, team meeting minutes and communicated to staff via communication boards and huddles. 4. Implement and Sustain Improvement teams consider the following factors when developing a strong implementation/change management plan: • Outstanding work to be completed prior to implementation (e.g. final revisions to change ideas based on PDSA's, embedding changes into existing workflow, updating relevant policies and procedures, etc.) • Education required to support implementation, including key staff resources i.e. team leaders • Communication required to various stakeholders, before, during and after implementation which includes resident and family council, staff, committee of management At this stage, teams will also identify key project measures to determine if the changes implemented resulted in improvement. This includes the following types of measures: Outcome Process Balancing Measures what the team is Measures key activities, tasks, Measures other parts of the trying to achieve (the goal) processes implemented to system that could be achieve goal unintentionally impacted by changes 5. Process to communicate outcomes Communication strategies are tailored to the specific improvement initiative. These include, but are not limited to: • Posting on unit quality boards, in common areas and in staff lounges • Publishing stories and results on the website, on social media or via the newsletter • Direct email to staff and families and other stakeholders • Handouts and 1:1 communication with residents • Presentations at staff meetings, Resident Council, Family Council • Huddles at change of shift • SURGE Learning • Use of Champions to communicate directly with peers • RNAO BPSO Knowledge Exchange and engagement sessions • Continuous Quality Improvement Subcommittee Meetings & Professional Advisory Committee Meetings The team ensures that regular reviews of the changes to ensure sustainability remains viable. This is typically conducted at the monthly CQI meetings and the project management meetings. Page 48 of 54 MODERATE ACTION: PROGRAM EVALUATIONS These are reviewed and updated quarterly at PAC-CQI. 1. Medication Program: In August 2025, reviews confirmed that all attending and on -call physicians were in good standing with the College of Physicians and Surgeons of Ontario. The committee monitored quarterly drug statistics and incident summaries throughout the year to maintain evidence -based practices. 2. Skin and Wound: A new Skin and Wound application was launched in June 2025, moving assessments from the previous UDA format to a dedicated platform. A subsequent upgrade was completed on November 4, 2025, supported by ongoing staff education to ensure early identification and assessment of wounds. 3. Restraints & PASDS: Terrace Lodge continued the proactive removal of bed rails for residents where they were no longer clinically indicated. Education sessions were conducted for staff and families regarding bed entrapment risks and the documentation of these conversations during the admission process. 4. Continence: Monthly audits in 2025 identified opportunities to improve product assignment and reduce overstocking in resident rooms. Specialized training with a First Quality representative was conducted in November 2025 to optimize product use and staff knowledge. 5. Falls: Clinical Pathways for Falls and Pain officially went live on November 27, 2025, providing a standardized framework for risk management. Additionally, comprehensive Arjo lift training was completed for staff on November 17 and 18, 2025, to enhance resident safety during transfers. 6. Responsive Behaviors: Staff recruitment and support for the BSO program continued, with two staff members attending Dementiability training in Q3 of 2025 to better meet the needs of residents with responsive behaviors. 7. Restorative Care: Our goals aim to maintain and improve the overall independence of residents in the program, maintain audit completion to ensure all staff charting and documentation is being completed accurately and within a timely manner; and increase education and resources available to staff regarding restorative care. The Manager of Program and Therapy is the lead of the annual review, revisions, and distribution of the resident and family satisfaction surveys, serving as a liaison between the Continuous Quality Improvement (CQI) committee and the Resident and Family Council. Residents are provided an opportunity to review the survey and provide feedback on the questions prior to its formal distribution. The 2025 Resident and Family Satisfaction Survey for Terrace Lodge reflected a high level of overall trust and satisfaction with the quality of life provided at the home. While the clinical and environmental services are rated exceptionally high, the data highlights clear trends regarding operational pressures and infrastructure consistency. Participation included 34 survey results with contributors including both residents and family members. The annual satisfaction survey is based on a calendar year rather than a fiscal year. This means the 2025 action plan was informed by 2024 data, while the current 2026 action plan is being developed using the results from the 2025 survey. The leadership team aims to provide blended learning opportunities for staff to engage with evidence -based research and further their skills, knowledge and confidence. These micro - modules will be presented by leadership members to the frontline teams via visual resources, electronic modules and communications, as well as verbal dictation from leadership or designates. Resident and Family Council will support the monitoring and implementation of our staff learning initiatives by providing their experience and knowledge of current practice, culture and outcomes of care via verbal or written discussion at regular Resident Council and Family Council Meetings. These insights will be transferred to the CQI-PAC Meetings and used to develop SMART goals and change frameworks as needed. Results were also shared with the Family Council during their March 2026 meeting to gather input for the 2026 Page 49 of 54 Quality Improvement Plan. Department -specific information has been disseminated to individual leads to ensure targeted improvements are integrated into daily operations. KEY SATISFACTION HIGHLIGHTS INCLUDE: 1. High Level of Overall Recommendation • Recommendation Rate: 93.55% of respondents would recommend Terrace Lodge to others. • Trust in Staff: Residents and families frequently described the staff as exceptional, compassionate, and attentive. • Respectful Care: 79.41 % of respondents rated the respect for resident dignity and privacy as Excellent. 2. Key Strengths: Environmental and Clinical Quality • Facility Upkeep: The physical environment is a major highlight, with 76.47% rating the upkeep of the home (paint, decor) and 69.70% rating the grounds -keeping as Excellent. • Nursing Services: Registered Nursing services, particularly medication dispensing, received a high satisfaction rating, with 72.73% of respondents scoring it as Excellent. • Safety & Independence: 87.88% of residents feel that staff allow them to be as independent as possible. 3. Critical Opportunities for Improvement • Call Bell Response & Staffing: Satisfaction with call bell response times is notably lower than other categories, with only 18.18% rating it as Excellent. Qualitative comments point to a perceived shortage of PSWs and staff "running down the halls" to manage workload. • Temperature Consistency: 23.53% of respondents are Dissatisfied with the temperature in the home. Comments indicate specific "cold blasts" in the Maple hallway and rooms being either too hot or too cool. • Laundry & Missing Items: 11.76% of respondents are Dissatisfied with laundry services. Concerns center on missing personal items, specifically socks and bedspreads. COMMUNICATION AND ACTION PLANNING The Manager of Programs and Therapy presented these 2025 results to the Resident Council at the Thursday January 22nd, 2026 meeting, initiating the development of the formal action plan in March 2026. Results were also shared with the Family Council during their April 2026 meeting to gather input for the 2026 Quality Improvement Plan. Additionally, the management team reviewed the survey data during PAC-CQI committee meeting on Wednesday, December 17th, 2025 and CQI committee meeting on Wednesday, March 25th 2026. Department -specific information has been disseminated to individual leads to ensure targeted improvements are integrated into daily operations. ACTION TAKEN TO IMPROVE RESULTS: In Q3 and Q4 the CQI team reviewed the areas of focus and formatted a plan to address the areas for improvement that were identified in the previous year's satisfaction survey and in alignment with the proposed 2026 survey goals. Opportunities for improvement were incorporated into the annual program implementation plans as well as the Health Quality Ontario, Quality Improvement Plan, where applicable. The Manager of Program and Therapy or the delegate(s) continue to provide updates at the council meetings. Survey Focus 2024 Survey 2025 Survey Implementation Actions Outcomes Outcomes September 2025 — March 2026: Continued How well staff 92% 57.69% Very collaboration with RNAO on Best Practice listen to you Satisfaction Satisfied / Yes Guidelines (BPG). While "Nursing Leadership" work was paused to prioritize clinical Page 50 of 54 pathways, the home hosted an RNAO tour in September 2025 to review BPG initiatives and frontline staff engagement. 51.86% Excellent / April — October 2025: Residents' Council Satisfied repeatedly identified washroom wait times and lift battery life as core operational concerns. In response, management audited lift battery Call bell 71% charging stations and integrated these specific response Satisfaction concerns into the Continuous Quality time (Note: 18.18% Improvement (CQI) program evaluations for rated response time targeted resolution as "Excellent" in the broader survey breakdown) 89.65% September —October 2025: Following Satisfaction specific requests from the Family Council regarding staff name tags, managers (Note: conducted structured floor audits and provided Staff Separated into direct, 1:1 reminders to staff to ensure individual consistent identification and strict adherence to identification elements in o 96.56/o Overall the home's dress code policy. (Name tags / Satisfaction Intro) 2024: 94% for nametags, 96.56% for introductions, and 100% for explaining role) September 29, 2025: Successfully transitioned the home to the interRAI LTCF Participation 80 77% system. This milestone included extensive staff in plan of Satisfaction 61.54% Satisfied clinical education through the Surge Learning care and Relias platforms to ensure resident data accuracy and more personalized, responsive care planning. June — October 2025: The Pleasurable Dining Committee actively addressed service workflows, specifically optimizing the breakfast service on the Birch unit. In October 2025, staff 60% received live demonstrations of the MealSuite Satisfaction ordering system, and residents participated in (Meal tours of the newly renovated kitchen space. Temperatures) April 2025: Completed a major dining room Pleasurable 93.11% Overall flooring renovation, carefully coordinated to Dining Satisfaction minimize resident disruption while upgrading the safety and aesthetic appeal of the shared 62.07% space. Exploration of sheer curtains was also Satisfaction initiated to optimize natural light and resident (Attractive privacy. Presentation) 2025 Themed Dining Calendar: Implemented an array of social engagement meals, including an 80s-themed comfort food night (April), a Cinco de Mayo celebration (May), a Father's Day lunch welcoming 25 guests Page 51 of 54 (June), "Talk Like a Pirate Day" featuring a seafood menu, and a "Country Hoedown" theme night. From March 31, 2025, to March 31, 2026, Terrace Lodge successfully implemented several key infrastructure and clinical initiatives to enhance the resident experience. A major flooring renovation was completed in the dining room in April 2025, coordinated to minimize disruption while improving the aesthetic and safety of the communal space. To further improve the home's atmosphere, sheer curtains were explored for installation in common areas and resident rooms to optimize natural lighting while maintaining privacy. Clinical care was significantly advanced through the November 27, 2025, go -live of Clinical Pathways for Pain and Falls, supported by intensive Arjo lift training for frontline staff on November 17-18, 2025. These efforts were complemented by a robust calendar of themed dining events designed to promote social engagement and satisfaction. Highlights included an 80s-themed comfort food meal in April, a Cinco de Mayo celebration in May, and a special Father's Day lunch in June that welcomed 25 guests. Later in the year, residents enjoyed "Talk Like a Pirate Day" with a seafood menu and a "Country Hoedown" theme, demonstrating the home's commitment to providing diverse and meaningful recreation opportunities alongside clinical excellence. INFRASTRUCTURE & ENVIRONMENT With gratitude and appreciation, a donor grand reopening event for the Terrace Lodge redevelopment was held on September 27, 2025. Further environmental improvements included hair salon renovations beginning in April 2025 and administrative office renovations completed in November 2025. Following resident feedback regarding the courtyard, dead tree limbs were pruned in the Birch courtyard to improve safety and aesthetics. To maintain comfortable temperatures during HVAC/chiller maintenance, staff were retrained on environmental controls (closing blinds/windows). CLINICAL EXCELLENCE AND TRAINING Clinical Pathways: The "Go -Live" for the Pain and Falls Clinical Pathways was established for November 27, 2025. This was supported by gap analyses and registered staff training throughout the fall. Specialized care initiatives included a new Skin and Wound lead was appointed in August 2025, coinciding with the implementation of a new tracking app to improve data accuracy for CQI meetings. Additionally, the Behavioral Supports Ontario (BSO) team expanded, introducing unit -specific binders to improve communication regarding resident -specific responsive behaviors. Looking to Emergency Preparedness, the home maintained rigorous safety standards, conducting monthly fire drills and a full annual evacuation drill on October 22, 2025. A comprehensive emergency planning meeting with first responders was held on October 31, 2025, to review Code Purple (Severe Weather) and other protocols. RESIDENT ENGGEMENT & INCLUSION As part of the 2025 Quality Improvement Plan (QIP), a DEI Gap Analysis was completed, leading to mandatory LGBTQ+ education for staff across all Elgin County homes in September 2025. This remains an on -going focus of our educational programing for staff as we enter the 2026 term. To enhance the spiritual and social supports available for our residents, Terrace Lodge also implemented new programming based on resident interest, including a Bible Study group and a Thanksgiving service with Communion. High -profile events such as Residents' Council Week and a Unique Vehicle Exhibit further bolstered social engagement. Bingo remains the top request from our residents and will be cemented in our activity programing for the upcoming year as well. Page 52 of 54 The Terrace Lodge CQI committee develops and submits a Quality Improvement Plan (QIP) to Health Quality Ontario annually. The QIP includes a progress report which captures the progress/lessons learned while the narrative summarizes the CQI journey in the prior year's QIP. The workplan outlines the aims, measures and change ideas for the 2026/2027 QIP. FOCUSED ACTION: 1. Access and Flow • Reduce the rate of potentially avoidable emergency departments visits to or below the provincial benchmark of 21.9 through: o Utilization of the standard RNAO Nursing Advantage Canada, Clinical Pathways assessments (Admission, Fall Prevention, Pain assessment, Palliative) o Continue our partnerships with local hospital, Facilities Operator Group (FOG) and pharmacy to continue work on "Transitions in Care" between hospital and long-term care o Development of processes to support the utilization of Nurse Led Outreach Team (NLOT), which will facilitate the application of nursing knowledge, skills and judgement in resident care to decrease avoidable ED visits. o Maintain use of Comfort Care Rounds for residents identified as being high risk for falls or having a precarious health condition o Audit the completion of medication reconciliation within 24 hours of admission and upon return from hospital to further support ED visit reduction and application of RNAO Transitions in Care guidelines. 2. Equitable Achieve 100 percentage of staff (all levels) who have completed relevant equity, diversity, inclusion and anti -racism education through: o Development and implementation of a DEI policy specific to long-term care home resident care and services utilizing the CLRI diversity tool kit o Maintain the enhanced orientation and onboarding process utilizing CLRI preceptor program; ensuring the process and resources remain up to date. o Develop and implement blended learning modules and micro -modules to increase staff engagement and optimize knowledge retention. In April of 2026 these improvements and applicable measures will be reviewed with resident and family councils, at which time their feedback and participation in upcoming efforts will be recorded and applied to our efforts. Further application of RNAO's best practice guidelines as they pertain to Transitions in Care will enhance our person & family centered care practices will contributing to the reduction of ED visits. Terrace Lodge will further the impact of their quality initiatives by using blended learning formats and the application of adult learning models to enhance the cultural awareness and knowledge of our staff. This action in collaboration with the implementation of Clinical Pathways — Palliative & End of Life tools will further contribute to the quality of life and care service provision within our home. Page 53 of 54 CONTACT & ARCHIVE LINK For further information please refer to the Terrace Lodge QIP progress report, narrative and workplan. The QIP is available on the County of Elgin Homes website https://www.elgincounty.ca/elgin-county-long- term-care-homes/ and documents posted on the QIP board located within the Home. The progress report details the action taken and the outcomes of the actions for the 2026/2027 QIP. x Joe Anne Holloway May 22, 2026 Director of Senior Services, Elgin County x Ashley Temple May 22, 2026 Home Administrator — Terrace Lodge, Elgin County x Leezanne Youn 2212026 Quality Improvement Coordinator, Elgin County Date of Review/ Approval Date of Review/ Approval Date of Review/ Approval Page 54 of 54