Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair

Corrective Actions Required: Ensure that all rooms and common areas are maintained in a good state of repair.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 8, 2024

Observations: Licensing toured the facility and observed four person in care's bedrooms that had chips and wall damage near the entry of the bathroom. The Manager stated there was ongoing maintenance occurring for wall damage.

Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Required: Ensure that all employees comply with the policies and procedures of the medication safety advisory committee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 8, 2024

Observations: Licensing audited the electronic medication administration record for persons in care from December 2 to 7, 2023. On December 5, 2023, there was one person in care who had no medications signed as administered for their 1900hr and 2000hr medications. The Medication Safety Advisory Committee policies indicate signing for medications once administered.

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:

Corrective Actions Taken By Licensee: Licensing received a copy of the recreational cannabis policy via email on December 19, 2023 from the Manager.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations: