Description: A licensee must ensure that all medications in the community care facility are safely and securely stored,

Corrective Actions Required: Ensure that all medications are safely and securely stored.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: August 30, 2024

Observations: This item has been carried forward from Routine Inspection dated July 5, 2023. On this date, Licensing audited the rooms of persons in care. Several medicated creams were observed that were not securely stored in rooms of persons in care.

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 and advisory committee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: August 30, 2024

Observations: This item has been carried forward from Routine Inspection dated July 5, 2023. On this date, Licensing audited the Medication Administration Records of persons in care. PRN medications were documented as administered without the result of the PRN effectiveness documented regularly and consistently as per policy.

Description: If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.

Corrective Actions Required: Ensure that if a person in care was admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care was made in accordance with this section within 30 days of admission.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: August 30, 2024

Observations: Licensing audited eight care plans for persons in care. Two persons in care had a short term care plan only when they had resided at the facility for more than 30 days. One of the care plans was dated April 2023 and one was dated May 2024.

Description: A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,

Corrective Actions Required: Ensure the community care facility is operated in a manner that promotes the health, safety, and dignity of persons in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: August 30, 2024

Observations: Licensing audited the care plans of eight persons in care and found that significant information had been erased, with minimal new information added afterward. The erased information was originally written in pencil.

Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,

Corrective Actions Required: Ensure that each person in care is weighed at least once a month.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: August 30, 2024

Observations: This item has been carried forward from Routine Inspection dated July 5, 2023. On this date, Licensing reviewed the weight records for persons in care. Multiple persons in care had months where weights had not been recorded.