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 toured the facility and observed damage located on the door frame of the spa room had been repaired and the staining in three person in care's carpets had been cleaned. The Manager stated the facility had implemented regular carpet cleaning to ensure ongoing compliance. Licensing observed a person in care's bathroom cabinet had been repaired.

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

To Be Corrected By:

Observations:

Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation,

Corrective Actions Required: Ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under section (2) to ensure that the employee continues to meet the requirements of this regulation.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 23, 2025

Observations: Licensing audited eight employee files and observed seven files did not include a performance review, and one file had a performance review last completed in 2019.

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 facility's medication cart and did not observe any medication that had been pre poured.

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

To Be Corrected By:

Observations:

Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited six employee records and observed all records included immunization status.

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

To Be Corrected By:

Observations:

Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing toured the facility and observed chemicals under the kitchenette on the third floor were securley stored and not accessible to persons in care.

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

To Be Corrected By:

Observations: