Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing tested the water temperature in five person in care's bathrooms. The water temperature was not more than 49 degrees Celsius.

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: a criminal record check for the person

Corrective Actions Required: Ensure staff have updated criminal record checks on file.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 22, 2024

Observations: Licensing reviewed twelve staff files and one staff file did not have a updated criminal record check.

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 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: March 22, 2024

Observations: Licensing observed the medication administration sheets for medication creams for March 2024 for ten persons in care and all ten persons in care did not have any staff signed for administration of medication creams. The Director of Wellness stated staff should be signing the medication administration sheets for administration of medication creams. Licensing also observed missed staff signature for March 18, 2024, 1700hour medications for one person in care on the medication administration sheet.

Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year

Corrective Actions Required: Ensure policies and procedures are reviewed and revised if necessary at least once each year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 21, 2024

Observations: Licensing observed the polices with a different facility name and not noted as reviewed and if necessary revised at least once each year.

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 licensee operates the facility 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: March 29, 2024

Observations: Licensing reviewed five person in care bathing charting for February and March 2024 and one person in care did not have any bathing charting in the months of February and March 2024. Staff stated that person in care did receive baths.

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

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited five person in care's bathrooms and observed no medicated creams.

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

To Be Corrected By:

Observations: