Raising the Alarm at Cedarwood Lodge. Sprinkler System Non-Existent.

Sault Ste Marie Fire Crews responded to an alarm at Cedarwood Interim LongTerm Care Home. July 6, 2018. 9:00 pm

How far would you go to ensure the safety and well being of a vulnerable, elderly loved one?

It might surprise you to learn that Cedarwood Lodge, an Interim Care and Treatment home, in the Sault’s north central area, is without a sprinkler system in the event of a fire.

On Friday, July 6, 2018, at approx. 9:00 pm, Sault Fire Services responded to an alarm at Cedarwood Lodge.

Cedarwood Lodge is located at the old Davey Home building- which later became Great Northern Nursing Centre, and then closed for a span of time – approx. 2 years.

Cedarwood Lodge was granted a license to operate as an Alternative Level of Care and Treatment facility (temporary) in May, 2014, issued by the Ministry of Health and Long-Term Care. It’s located at the north-west section of Third Line and Great Northern Road. http://www.northeasthealthline.ca/displayservice.aspx?id=166198

The above link notes Cedarwood as: ‘Description: Long-term care home * 24-hour nursing and personal care * access to a doctor and other health professionals * 50 interim beds.’

Cedarwood can also be found here: http://publicreporting.ltchomes.net/en-ca/File.aspx?RecID=18171&FacilityID=21320

Cedarwood is owned and operated by a private, for-profit corporation, Autumnwood Mature Lifestyle Communities Inc., based out of Sudbury, Ontario. Their role is specific to the terms of the license, granted under the Ontario Ministry of Health and Long-Term Care Homes Act. The license expires in 2020. Autumnwood ML does not own the building. Universalcare Canada Inc. is listed as ‘Management Firm’ for Cedarwood.

Cedarwood opened amid mounting pressures on Sault Area Hospital’s budget, and the strain of long-term care beds not readily available in our community. Alternative level of care – or ALC beds were crippling the capacity for healthcare delivery at the Sault hospital.

A building which sat vacant, and at one point was used as a staging site for a movie shot in and around the Sault, became a potential, and stated, ‘temporary’ option.

This building had already been used for two separate nursing homes, and is geographically positioned near the hospital.

Folks entering into Cedarwood as ALC patients, were to be moved as interim residents. When a bed became available in, The FJ Davey Home, or Extendicare Mapleview or Extendicare VanDaele or the Finn Resthome, a move to one of those locations was the intention.

The Sault is one of hundreds –  thousands – of communities across this province buckling under the weight of a long-term care bed crisis – And the term ‘bed’ is how the bean-counters state it.

With no clear path laid out for reprieve, it is difficult to be the person waiting for the bed, the loved ones of that individual, and by extension  a community’s capacity to rally resources in an effort to support the individual as they transition to long-term care.

A local woman, Patricia Culverhouse – and advocacy group, ‘Voice for the Elderly’ have shared their concerns with Superior Media –  on the issue of sprinklers – and the lack thereof – at Cedarwood.

Several documents made available through Freedom of Information (FOIA) – attained by Patricia Culverhouse are pertinent to the discussion, and were shared with Superior Media.

Armed with newly acquired documents, a copy of Cedarwood’s License, pertinent sections of the Fire Code and above all a sense of duty to vulnerable seniors, Culverhouse and  ‘Voice for the Elderly’ are pressing for a formal enquiry into whether or not sprinklers for the building where Cedarwood is located should have been mandated for installation prior to a license being granted by the Ministry of Health and Long-Term Care.

‘Voice for the Elderly’, wants to know why there’s no sprinklers in the local interim, long term care home and most importantly, how a facility with a 5 year, non-renewable/transferable license that expires in May, 2020 was given until 2025 to phase-in sprinklers.

“Five years past the expiry date of the license to finally install potentially lifesaving sprinklers is beyond baffling.” says Patricia Culverhouse, whose late husband was among the first residents moved there by the Community Care Access Centre (CCAC).

“Being vacant from June, 2013 until May, 2015 when the license was issued, would have been the best time to install sprinklers.” said Culverhouse. “They had two years, so why on earth would they put this off, leaving vulnerable seniors at risk.”

Documents show this was the second time the building in question was closed for an extensive period of time. The first time was from 2004 after the Davey Home left, until new operators took over in 2006.

“One letter from 12-30-13, asks for evidence of an approval of a ‘current’ fire plan from the Fire Chief, so wouldn’t the criteria of being ‘current’ apply to sprinklers mandatory in all newly licensed homes since 1997?” Culverhouse queried.

In a selection of the documents provided through FOIA, Fire Inspection Reports conducted by Sault Fire Services refer to Cedarwood Lodge under ‘Location Type’ as Nursing Home True (April 27, 2015 and others) and B B Retirement Home (April 22, 2015 and others).

Quotes from a 2009 Sault Star article stated by a then Ministry of Health official when the previous facility, the ‘Great Northern Nursing Home’ was closed to further admissions because of compliance issues, supports Culverhouse’s suspicions by pointing at sprinklers as possibly being among the problems at that time.

Excerpt from article: “Morrison said compliance issues at the aging facility also played a part in the order, which came down earlier this month. It’s not surprising to us because of the state of the building. . . . It is on the edge of compliance,” said Remy Beaudoin, Executive Director of the North East Local Health Integration Network, which flows provincial dollars to SAH.” (April 29, 2009).


Ontario Fire Code Legislation enacted on January 01, 2014 went a step further than the 1997 legislation (OFC), with mandatory sprinklering of all existing buildings already “containing” a Care Occupancy or Care and Treatment Occupancy with a phase-in period for installation in consideration to future upgrades and working around residents.

Accordingly the Fire Code says, ‘Requirements for buildings shall be determined by their occupancies …’, “buildings ‘containing’ a home described in the section… that is a care occupancy or care and treatment occupancy shall be sprinklered’.

Documents Culverhouse received through FOIA show there was no occupancy at the building in question, and that being vacant without a licensed operator, could have meant that sprinklers would be necessary on start-up.

Culverhouse maintains that the building being granted a 10 year extension for installation of sprinklers after the license was granted doesn’t make sense.

“The operator of Cedarwood was issued a license pursuant to section 50 of the Long Term Homes Act (2007) expiring in 2020 and was given til 2025 to phase in a sprinkler fire suppression system.”

Culverhouse feels that her concerns have not elicited a satisfactory response from Sault Fire Services, and she decided to go public and request a formal enquiry.

This issue of sprinklers was first raised by The Family Council at Cedarwood Lodge shortly after it opened. In an excerpt from a letter to former Fire Chief Mike Figliola, the Family Council wrote:

“Nov. 14/16 – Dear Chief Figliola,

Recently you received a letter about the lack of automatic sprinklers in Cedarwood Lodge and its come to our attention that you appear unwilling to respond in kind to the concerns raised. We’ve frail family members living in the facility and feel our anxieties are just, especially considering the age of the structure and its history.

It was a proactive Cedarwood Family Council that complained about the old blackened condition of fire hoses and related equipment back in November of 2015, a full 6 months after opening that led to your order that it all be replaced immediately.

Lately one of our members called Fire Services several times about sprinklers and received explanations that didn’t correspond with the fact the building was under a new licensee, no interim only LTC licence was, or could be transferred –  nor was one maintained throughout its two year vacancy where it was last used to shoot a movie, thus it was not an LTC home then.”

“As I see it” shared Culverhouse, “The fact that sprinklers are determined by the occupancy of a building and that there was no occupancy in Cedarwood until after May 19th, 2015, that this gap in ‘occupancy’ has created an untenable situation if this is the determining factor.”

The Ontario Fire Code (OFC) “Road Map to the Fire Code found here: https://www.mcscs.jus.gov.on.ca/english/FireMarshal/CareOccupanciesCareandTreatmentOccupanciesRetirementHomes/ARoadMaptotheFireCode/RoadMap.html alludes to the fact the building must contain a Care and Treatment Occupancy on Jan 01, 2014 to comply for sprinklers under the current legislation and subsequent phase-in period.

“The occupancy and thus the future license would have been necessary for any decision regarding sprinklering.” Said Culverhouse.

“If the building was vacant on two occasions, 2004 – 2006 and 2013 – 2015 with no care and treatment occupancy, how did they avoid installing sprinklers then? Why did the operator with a 5 year non- renewable/transferable License get 10 years to install sprinklers? Why was the operator given a phase-in period to install sprinklers when the Fire Code very clearly says the building must have contained a care occupancy to comply for time to work around residents? Why did the operator get permission to open without sprinklers even though the building was vacant for 2 years?”

Culverhouse added, “Fire codes say the criteria for sprinklers is based on occupancies but what I’m getting from the fire department is the building codes.”

Sault Fire Service Deputy Chief Paul Milosevich – Inspection Division, in an interview with Superior Media, stated that he is extremely sensitive to Culverhouse’s concerns.

“The Ontario Fire Code and our authority to deal with issues of non-compliance are rectified through our inspection process.  We issue direction and order corrective action (when required) directly to the ownership group. The issue of Licensing is not within the scope of the local Fire Service or our legislative authority. This is governed through the Ministry of Health and Long Term Care, under the Long-Term Homes Care Act.  Similarly, the approval concerning how the building functioned in the past, prior to, and/or any construction history is determined by the Ontario Building Code through the Chief Building Officials office and not the OFC and/or our authority under the FPPA.

Once this facility (Cedarwood) was granted licensing, the applicable Section of the OFC (Ontario Fire Code) is “Section 9.4 – Health Care Facilities.” he said.

“A building that contains a care occupancy that satisfies the construction requirements of the Building Code as it read on or after April 6, 1998, is exempt from Section 9.7 because those editions of the Building Code have provisions that meet or exceed the provisions of Section 9.7.”

Section 9.7 is a ‘Retrofit Section’ that came into legislative effect on January 1, 2014, with a phased compliance schedule. It addresses minimum mandatory retrofit requirements for existing buildings containing care occupancies and retirement homes regulated under the Retirement Homes Act, 2010.

The requirements for building that are covered by this part of the Act ‘shall be determined by their occupancies as regulated by the appropriate Sections in’

Excerpt from Ontario Fire Code as it relates to sprinklers.

Section 9.7 – Buildings with a Care Occupancy OR Retirement Home.

As such, the effective compliance date for facilities governed under Section 9.4 – Health Care Facilities, can be found in OFC compliance schedule,  Subsection –  9.1.3 Schedule of Compliance.

Compliance time for health care facilities, care occupancies and retirement homes (1) It is the responsibility of the owner of a building containing a home or hospital described in Section 9.4 to comply with Article as of “January 1, 2025”.

(2) It is the responsibility of the owner of a building to which Section 9.7 applies to comply with

(a) Article as of March 1, 2014,

(b) Articles, and as of January 1, 2015,

(c) Articles and as of January 1, 2016, and

(d) Article as of January 1, 2019.

“As a Fire Service, specifically the Sault Ste. Marie Fire Prevention Division, we are tasked with enforcing the Ontario Fire Code (OFC)  prescriptive requirements.” said Deputy Chief Milosevich. “I understand and appreciate their concern (Voice for the Elderly) regarding sprinkler compliance.  However, the Ontario Fire Code is prescriptive and sets out the compliance date concerning sprinklers for this facility as:  January 1, 2025.”

“We aim to ensure facilities such as Cedarwood Lodge indeed meet current and future prescriptive time frames described within the OFC.” he said.  “We cannot exceed what the OFC prescribes and allows us to enforce.  The Fire Protection and Prevention Act (FPPA) and the Ontario Fire Code is Provincial Law. Our office and the Provincial “Ontario Municipal Fire Prevention Officers Association” of Ontario (OMFPOA) were at the forefront in promoting the legislative change requiring sprinklers within these types of facilities. We further provide extensive training to staff in these facilities and diligently enforce the OFC within all local  “Vulnerable Occupancies” on a scheduled basis.”

Staff are certainly at risk in the event of a fire. Protocols and fire drills are undertaken – but when that alarm goes off for real – at say 10:00 pm and people without their hearing aids don’t hear the alarm – because they’re asleep or just don’t like to wear them, are going to be so dazed and confused that time will be a luxury – not the reality. Medication could be considered a relevant factor here too.

The list goes on for the physical challenges faced by staff to evacuate in the event of a fire. Even with military precision, they would be dealing with a myriad of mobility issues, and with some individuals who are in the throws of dementia and Alzheimer’s.

Sometimes behaviours that would have seemed out of character for the elderly person years ago – are showing up as aggression – withdrawal – stubbornness – defiance. Smoke coupled with vision loss – breathing issues would exacerbate an already chaotic situation. In an escalating crisis – the staff would have their hands full.

Culverhouse believes that sprinklers should be demanded today – not in 2025 – when the licensee will no longer (potentially) have the license to operate. “Sprinklers at Cedarwood would allow for all of the residents and staff to have a fighting chance.”

Sault Fire Crews responded to an alarm at Cedarwood Lodge, Sault Ste. Marie, Ontario. July 6, 2018. photo by lynne brown/superior media

This issue is vital to any community planning – community development conversation.

Building Codes and Fire Codes in the province have made significant progress.

Deputy Chief Paul Milosevich is 100 % right. The Sault Professional Firefighters, together with professional firefighters across the province – the Ontario Fire Marshall’s Office – were on the forefront of a movement to get legislative change – specifically sprinklers in building occupancies where vulnerable people live. Their lobbying effort created meaningful Ontario government policy. It’s hard work to do that. And as a result of that hard work we now have robust provincial legislation.

The genesis for any change to legislation sometimes comes as a result of a tragic event. Patricia Culverhouse, Voice for the Elderly, has written to Mayor Provenzano, (May 25, 2018) requesting an enquiry into whether or not sprinklers should have been installed prior to the license being granted at the building in question.

“So – here we are.” said Culverhouse. “Cedarwood Lodge – sprinklers… To be – or not to be? That is the question.”

Sault Fire Crews responded to an alarm at Cedarwood Lodge, Sault Ste. Marie, Ontario. July 6, 2018. photo by lynne brown/superior media


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