Infection prevention and control lapses
An Infection Prevention and Control (IPAC) lapse is a departure from infection prevention and control standards that could result in infectious disease transmission through exposure to blood or bodily fluids.
Infection Prevention and Control lapses can occur at routinely inspected personal service settings (e.g., nail salons, tattoo, or piercing studios) and settings not routinely inspected by public health including regulated health professional settings (e.g., physician or nurse practitioner, dental, or physiotherapy clinics).
Infection Prevention and Control lapses are disclosed to the public in accordance with the provincial Infection Prevention and Control Complaint Disclosure Protocol, 2022.
Southeast Public Health reports on premises where an infection prevention and control lapse was identified through the assessment of a complaint or referral, or through communicable disease surveillance. It does not include reports of premises which were investigated following a complaint or referral where no infection prevention and control lapse was ultimately identified.
These reports are not exhaustive, and do not guarantee that those premises listed and not listed are free of infection prevention and control lapses. Identification of lapses is based on assessment and investigation of premises at a point-in-time, and these assessments and investigations are triggered when potential infection prevention and control lapses are brought to the attention of our medical officer of health.
Reports will be posted for a period of two (2) years, on a premises-by-premises basis.
To view a full investigation report for any posted lapse, please call 613-549-1232, extension 4722 or email our Infection Prevention and Control team.
Lapse reports
Almonte Nails and Spa – January 28, 2026 (initial report)
Premise or facility under investigation
Almonte Nails and Spa, 10 Houston Drive, Almonte, Ontario
Type of premises or facility
Multi-service personal service setting
Date Board of Health became aware of IPAC lapse
January 19, 2026
Date of initial report posting
January 28, 2026
How the Board of Health became aware of potential IPAC lapse
Complaint
Summary description of IPAC lapse
- Complaint received by customer who believes she contracted a fungal nail infection from the premises from a pedicure received in the summer of 2025
IPAC lapse investigation
Did the IPAC lapse involved a member of a regulatory college
No
If yes, was the issue referred to the regulatory college
No
Were other agencies notified?
No
Corrective measures recommended or implemented
- All reusable equipment and instruments, including dremel bits, must be thoroughly reprocessed between clients in accordance with established infection prevention and control protocols.
- All required reprocessing steps must be completed consistently for every reusable piece of equipment and instrument.
- All portable dremel devices used for pedicure services must be removed from use immediately and may only be reinstated with written authorization from a Public Health Inspector.
- Single use equipment and instruments must not be reused between clients under any circumstances. All single use equipment and instruments must be discarded immediately after use.
- Used single use equipment and instruments must not be stored on site for future use and must be disposed of promptly.
Method(s) used to correct identified deficiencies:
Educational
Owner/operator was provided with on-site instruction and education and provided with educational materials on instrument/equipment cleaning and disinfection.
Additional comments
Inspection report issued to operator itemizing deficiencies and corresponding corrective actions required. All critical deficiencies required for continued operation of the premises were corrected at the time of inspection. A reinspection was conducted to confirm correction of all other deficiencies.
Greater Napanee Health Home – December 1, 2025 (final report)
Premise or facility under investigation
Greater Napanee Health Home – Lenadco Complex, 310 Bridge Street West Suite CO1 Unit A, Napanee, Ontario, K7R 0A4
Type of premises or facility
Primary Care Clinic
Date Board of Health became aware of IPAC lapse
December 1, 2025
Date IPAC lapse was linked to the premises/facility
December 3, 2025
Date of initial report posting
March 12, 2026
How the Board of Health became aware of potential IPAC lapse
Complaint
Summary description of IPAC lapse
- On-site sterilizer was not operated according to best practices to verify that each sterilization cycle met the required conditions
- No sterilization record log
- No one-way workflow in reprocessing area to prevent cross contamination
- No formal education, training, and certification of staff performing reprocessing
- Improper packaging of sterilized equipment, including missing labels (i.e. lot numbers, contents), overcrowding, and placement of instruments in locked positions that prevented steam from contacting all surfaces
IPAC lapse investigation
Did the IPAC lapse involved a member of a regulatory college
Yes
If yes, was the issue referred to the regulatory college
Yes – College of Physicians and Surgeons Ontario (CPSO) and College of Nurses Ontario (CNO)
Were other agencies notified?
Yes – Risk assessment consultations with Public Health Ontario and Ministry of Health.
Corrective measures recommended or implemented
- Clinic was required to discontinue on-site reprocessing of re-usable medical equipment, effective December 3, 2025.
- Clinic was advised to use single-use disposable items and/or contract a third-party to sterilize re-usable equipment.
- Sterilizer (Tuttnauer EZ10) maintenance performed on December 8, 2025 and passed sterilization parameters.
Additional comments
- Re-inspection performed December 8, 2025
- Clinic utilizing single-use disposable equipment and contracted a third party to reprocess re-usable equipment
- Staff completed Public Health Ontario reprocessing modules and on-site sterilizer training
- The clinic agrees to notify Public Health prior to resuming any reprocessing activities.
Ivy Beauty Bar – October 29, 2025 (initial report)
Premise or facility under investigation
Ivy Beauty Bar, 545 McNeely Avenue, Carleton Place, Ontario
Type of premises or facility
Personal service setting
Date Board of Health became aware of IPAC lapse
October 17, 2025
Date of initial report posting
October 29, 2025
How the Board of Health became aware of potential IPAC lapse
Compliance inspection
Summary description of IPAC lapse
- Inadequate reprocessing (cleaning and disinfection) of re-usable manicure, pedicure and waxing equipment.
- Single use items not discarded immediately after each client and being reused on different clients.
- Disinfectant(s) not used according to manufacturer’s directions or the Guide to Infection Prevention and Control in Personal Service Settings, third edition best practices.
IPAC lapse investigation
Did the IPAC lapse involved a member of a regulatory college
No
If yes, was the issue referred to the regulatory college
No
Were other stakeholders notified?
Yes – Public Health Ontario Laboratory
Corrective measures recommended or implemented
- Equipment and instruments are to be maintained in good repair and in a sanitary manner. Equipment is to be routinely inspected by operator and any equipment that is rusty or in disrepair is to be discarded.
- All contaminated reusable equipment must not be stored in or around the service area.
- All reusable equipment must be appropriately reprocessed. The operator must follow best practices when reprocessing reusable equipment. Reusable equipment and instruments are to be cleaned and disinfected between each client in accordance with the Guide to Infection Prevention and Control in Personal Service Settings third edition.
- All single-use disposable equipment and instruments must be discarded immediately after use.
- Disinfectant solutions are to be used, prepared, maintained, and disposed of according to the manufacturer’s instructions. The use of sodium hypochlorite (bleach) or 70-90% isopropyl alcohol must be prepared, maintained and disposed of according to the Guide to Infection Prevention and Control in Personal Service Settings, third edition best practices.
- Store all equipment and instruments in a manner to protect from contamination.
- Do not use unapproved methods or devices (ex. ultraviolet light) for disinfection or sterilization of reusable equipment.
- Ensure disinfection records are maintained and retained for minimum of two years. The Public Health Inspector provided operator with disinfection record template – this can be photocopied or found online.
Additional comments
Inspection report issued to operator itemizing deficiencies and corresponding corrective actions required. All critical deficiencies required for continued operation of the premises were corrected at the time of inspection. A reinspection was conducted to confirm correction of all other deficiencies.
Educational: Owner/operator was provided with on-site instruction and education and provided with educational materials on instrument/equipment cleaning and disinfection.
Almonte Nails and Spa – July 28, 2025 (final report)
Premise or facility under investigation
Almonte Nails and Spa, 10 Houston Drive, Almonte, Ontario
Type of premises or facility
Personal service setting
Date Board of Health became aware of IPAC lapse
June 17, 2025
Date of initial report posting
July 28, 2025
How the Board of Health became aware of potential IPAC lapse
Complaint
Summary description of IPAC lapse
- Operator reusing single use items, such as buffers, exfoliators and files.
IPAC lapse investigation
Did the IPAC lapse involved a member of a regulatory college
No
If yes, was the issue referred to the regulatory college
No
Were other agencies notified?
No
Corrective measures recommended or implemented
- All items designed for a single use must be discarded immediately after they are used.
Method(s) used to correct identified deficiencies:
Educational: Education provided regarding single use items.
Additional comments
Part 1 Offence Notice
Final report
Date of final report:
July 9, 2025
Brief description of corrective measures taken:
Part 1 Provincial Offences Notice issued under Ontario Regulation 136/18 Personal Service Settings Section 10 (5)
The date all corrective measures were confirmed to be completed:
July 9, 2025
Limestone Medical Clinic and Foot Management Program – June 20, 2025 (final report)
Premise or facility under investigation
Limestone Medical Clinic and Foot Management Program – 1100 Princess Street, Kingston, Ontario K7L 5G8
Type of premises or facility
Primary Care and Foot Care Clinic
Date Board of Health became aware of IPAC lapse
June 20, 2025
Date IPAC lapse was linked to the premises/facility
June 24, 2025
Date of initial report posting
July 16, 2025
How the Board of Health became aware of potential IPAC lapse
Complaint
Summary description of IPAC lapse
- Sterilizer not maintained as per manufacturer’s instructions for use
- Sterilizer not challenged with a biological indicator
- Inadequate education, training, and certification of staff performing reprocessing
IPAC lapse investigation
Did the IPAC lapse involved a member of a regulatory college
Yes
If yes, was the issue referred to the regulatory college
Yes
Were other stakeholders notified?
No
Corrective measures recommended or implemented
- The clinic and foot care nurse were verbally instructed to suspend all services involving autoclave sterilization until a proper sterilization process for reusable medical and foot care equipment was established.
- Sterilizer was successfully challenged with a spore test.
- On June 24, 2025, the operator voluntarily and permanently discontinued the use of reusable medical equipment.
Kims Foot Care Services – March 17, 2025 (final report)
Type of premises or facility
Advanced Foot Care Nurse
Date Board of Health became aware of IPAC lapse
March 17, 2025
Date IPAC lapse was linked to the premises/facility
March 17, 2025
Date of initial report posting
March 28, 2025
Date of initial report update(s), if applicable
March 17, 2025
How the Board of Health became aware of potential IPAC lapse
Complaint
Summary description of IPAC lapse
- The foot care nurse did not clean items with detergent and water, and did not sterilize foot care equipment using an autoclave.
- The foot care nurse used a liquid sterilant, which cannot maintain equipment sterility to point of use and does not follow best practices.
- Reusable foot care equipment must be sterile to the point of use.
- Liquid sterilant and disinfectant was not applied according to the manufacturer’s instructions and was used without appropriate cleaning.
IPAC lapse investigation
Did the IPAC lapse involved a member of a regulatory college
Yes
If yes, was the issue referred to the regulatory college
Yes
Were other stakeholders notified?
No
Corrective measures recommended or implemented
- The foot care nurse was verbally directed to discontinue services until a proper process was established to clean and then sterilize all reusable foot care equipment using an autoclave.
- The operator voluntarily elected to cease providing foot care services effective March 18, 2025
Lan Nail and Spa – June 13, 2024 (final report)
Premises or facility under investigation (name and address)
Lan Nail and Spa
546 Bath Road Unit 4, Kingston, Ontario K7M 2Y3
Type of premises or facility
Personal Service Setting – esthetics
Date Board of Health became aware of IPAC Lapse
May 31, 2024
Date IPAC lapse was linked to the premises/facility
May 31, 2024
Date of initial report posting
June 13, 2024
Date of initial report update(s), if applicable
Not Applicable
How the Board of Health became aware of potential IPAC lapse
Routine inspection
Summary description of IPAC lapse
- Identified non-compliance in reprocessing reusable instruments
- All reusable instruments were being disinfected with ready to use disinfectant that was diluted with water
- Diluted product was below the manufacturer’s required concentration rendering the product ineffective as a disinfectant
- Setting did not use disinfectant according to the manufacturer’s instructions
IPAC lapse investigation
Did the IPAC lapse involved a member of a regulatory college
No
If yes, was the issue referred to the regulatory college
NA
Were other stakeholders notified?
No
Corrective measures recommended or implemented
- All reusable devices were collected and reprocessed – recleaned with soap and water and disinfected in undiluted disinfectant for the required contact time as per manufacturer instructions.
Re-inspection performed June 14 and July 30, 2024
- Both follow up inspections confirmed reusable equipment is being cleaned and disinfected in appropriate level of disinfectant as per best practice.
Corner Stone Stylists – June 11, 2024 (final report)
Premise or facility under investigation
Corner Stone Stylists, 117 King Street East, Gananoque, Ontario K7G 1G3
Type of premises or facility
Multi-service personal service setting
Date Board of Health became aware of IPAC lapse
May 17, 2024
Date of initial report posting
June 4, 2024
Date of initial report update(s), if applicable
June 14, 2024
How the Board of Health became aware of potential IPAC lapse
Routine inspection
Summary description of IPAC lapse
- Fail to reprocess reusable equipment properly and fail to use single-use disposable equipment where required when providing services: Facial waxing, ear lobe piercing and makeup services. Risk of bloodborne pathogen transmission is very low, however risk of infection is greater.
IPAC lapse investigation
Did the IPAC lapse involved a member of a regulatory college
No
If yes, was the issue referred to the regulatory college
No
Were other agencies notified?
No
Corrective measures recommended or implemented
- Do not provide ear piercing, waxing or make-up services until the Health Unit has approved your processes.
- Remove the Stud-Ex piercing equipment, waxing equipment and make-up from the premises immediately.
- This order is to be posted at the entrance to Corner Stone Stylists by a Public Health Inspector and must only be removed by a Public Health Inspector.
- To reinstate services affected by this order, a written plan must be submitted to Southeast Public Health. The plan must demonstrate what actions you will take to comply with the Personal Services Reg. 136/18 and must contain written procedures for cleaning and disinfecting re-usable equipment.
- You are required to complete Southeast Public Health notification form to advise what services you intend to provide at your premises.
Method(s) used to correct identified deficiencies:
Educational
Other: Inspection Reports
Other: Obstruction Warning Letter
Other: Sec. 13 Order under the Health Protection and Promotion Act, R.S.O. 1990
Date(s) any order(s) or directive(s) were issued to the owner/operator (if applicable):
May 24, 2024
Final report
Date of final report:
June 11, 2024
Brief description of corrective measures taken:
- Owner/Operator stopped providing facial waxing, ear lobe piercing and make-up services as per the sec. 13 Order.
- Owner/Operator has provided written notice of the intent to re-instate facial waxing and make-up services.
- The owner/operator has complied with all requirements of the Order and under the Personal Services Regulation and has demonstrated this with written procedures and also during an inspection.
The date all corrective measures were confirmed to be completed:
June 11, 2024
Additional comments
The sec. 13 Order has been rescinded and the owner has resumed providing the following services: Facial waxing and make-up services in accordance with the Personal Services Regulation and IPAC Guidelines.