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

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing conducted a facility tour and observed minimal wear and tear on the walls. Additionally, any larger holes in the walls were fixed.

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

To Be Corrected By:

Observations:

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: character references in respect of the person

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing reviewed 16 staff files and all staff files had two reference checks on file.

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

To Be Corrected By:

Observations:

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

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the medication room, cart, and documentation and observed no pre-poured medication or medication without staff signatures.

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

To Be Corrected By:

Observations:

Description: Clear and up to date records of immunization status kept for each person in care

Corrective Actions Required: Ensure clear & up to date records of immunization status are kept for each person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 18, 2023

Observations: Licensing reviewed 16 person in cares charts and 13 persons in care did not have a record of immunization.

Description: A care plan must include all of the following: a plan to address if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing reviewed the care plan of one person in care who used a pin lock lap belt restraint and noted there was a restraint care plan in place.

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

To Be Corrected By:

Observations:

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 a plan for following up on any falls suffered by a person in care

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing reviewed the care plans of 16 persons in care and noted that 15 persons in care had a care plan in place to follow up on falls suffered and one falls care plan was in development as a person in care was newly admitted.

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

To Be Corrected By:

Observations: