Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.

Corrective Actions Required: Ensure all persons admitted to the community care facility comply with the Province's immunization and tuberculosis control programs.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 31, 2025

Observations: Licensing audited three person in care's records and one person in care did not have an immunization record.

Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable

Corrective Actions Required: Ensure to keep a record for each person in care showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 30, 2025

Observations: Licensing audited three person in care's records and one person in care did not have consent to be admitted to the facility.

Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,

Corrective Actions Required: Ensure each person in care has consent in writing from the person in care or a parent or representative of the person in care, to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 7, 2025

Observations: Licensing audited three person in care's records and one person in care did not have consent in writing to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.

Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address an assessment of the nature of the risk of falling presented by the person in care

Corrective Actions Required: Ensure that care plans for persons in care who receives a type of care described as Long Term Care or who may be prone to falling, include an assessment of the nature of the risk of falling presented by the person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 31, 2025

Observations: Licensing audited three person in cares care plans and one of the care plans did not contain an assessment of the nature of the risk of falling presented by the person in care.

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 each month.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 31, 2025

Observations: Licensing audited the weight records for persons in care. Licensing observed that weights were not recorded between April 2024 and December 2024 by staff.

Description: A licensee must keep the following records in respect of each employee: criminal record check results,

Corrective Actions Required: Ensure criminal record check results are kept for each employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 31, 2025

Observations: This item has been carried over from Routine Inspection dated Sep 14, 2023. Licensing audited two staff files, and one did not contain a criminal record check, while the other had an expired criminal record check.

Description: A licensee must keep the following records in respect of each employee: character references,

Corrective Actions Required: Ensure to keep records of character references in respect of each employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 31, 2025

Observations: This item has been carried over from Routine Inspection dated September 14, 2023. Licensing audited two staff files, and one staff file contained only one reference check.

Description: A licensee must keep the following records in respect of each employee: a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.

Corrective Actions Required: Ensure to keep records of performance reviews for employees.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 31, 2025

Observations: Licensing audited two staff files and one did not contain a record of a performance review.