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A senior woman with dementia, who was known to be an escape risk, fell head first to her death in April after easily removing the windows in her room at Carlingview Manor, according to a damning inspection report released by the province.

It took the woman less than two minutes to take the windows from their frames at the long-term care home and plummet to the ground, according to security footage.

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The windows, which were supposed to open no more than 15 centimetres to prevent falls, were in poor repair, not inspected regularly and routinely removed by cleaning staff, sometimes in front of residents, the report from the Ministry of Health and Long-Term Care found. Cleaning staff could easily take the windows out of their frames without the help of special tools, according to the report, and sometimes had difficulty putting them back in securely.

After the woman’s death, every accessible slider-style window in the eight-storey building was bolted shut.