Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: evidence that the person has complied with the Province’s immunization and tuberculosis control programs.

Corrective Actions Required: A licensee must not employ a person in a community care facility unless the licensee has obtained evidence that the person has complied with the Province's tuberculosis control programs.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: March 27, 2022

Observations: Licensing audited four staff files and one staff file did not have a record of a tuberculosis test.

Description: A licensee must make a policy respecting all of the following the engagement by persons in care in restricted activities, other than the consumption of medical cannabis, on the premises

Corrective Actions Required: Licensee must make a policy respecting the engagement by persons in care in restricted activities, other than the consumption of medical cannabis on the premises.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: March 27, 2022

Observations: Licensing reviewed the facility's policy and procedure manual which did not include a policy on persons in care consuming or storing non medical cannabis.

Description: The medication safety and advisory committee must establish and review as required policies and procedures in respect of the safe and effective storage, handling and administration of the person in care’s medications, in compliance with the Pharmacists, Pharmacy Operations and Drug Scheduling Act

Corrective Actions Required: The medication safety and advisory committee must establish and review as required policies and procedures in respect of the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacists, Pharmacy Operations and Drug Scheduling Act

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: March 27, 2022

Observations: Licensing reviewed the facility's policy and procedure manual, which did not include a medication policy provided by, or reviewed by, the medication safety and advisory committee.

Description: Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care,

Corrective Actions Required: Ensure there is agreement to the use of a restraint given in writing by both the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: March 27, 2022

Observations: Licensing observed three person in care's beds had bed rails to restrain them for safety purposes at night. Manager stated there was not have an agreement for the use of the restraint by their representatives, nor did Licensing observe an agreement in the person in care's files.

Description: Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the medical practitioner or nurse practitioner responsible for the health of the person in care.

Corrective Actions Required: Ensure there is agreement to the use of a restraint given in writing by both the medical practitioner or nurse practitioner responsible for the health of the person in care.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: March 27, 2022

Observations: Licensing observed three person in care's beds had bed rails to restrain them for safety purposes at night. Manager stated there was not an agreement for the use of the restraints by the medical practitioner or nurse practitioner responsible for the health of the person in care, nor did Licensing observe an agreement in the person in care's files.