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 in the community care facility are safely and securely stored,

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 16, 2023

Observations: Licensing inspected the medication cabinets at the facility. Both cabinets have broken locks that were not consistently locked or able to be locked easily.

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: Ensure that character references are obtained for an employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 16, 2023

Observations: Licensing reviewed staff files. One staff file did not have any character references for the staff person.

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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs.

Corrective Actions Required: Ensure to obtain evidence that the employee has complied with the Province's immunization and tuberculosis control program.

Corrective Actions Taken By Licensee:

Actions Required By Licensing:

To Be Corrected By: March 16, 2023

Observations: Licensing reviewed staff files. One employee file did not have a record of a TB test result.

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 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 16, 2023

Observations: Licensing inspected the medication cabinets. There were several issues noted on the last pharmacist inspection such as: medications with an expiry once opened were not labeled with open/discard dates; daily shift counts were not being completed with two signatures consistently; audit of narcotic and controlled substance practices was not performed monthly; the refrigerated medications were not stored separate from food; outcome and effectiveness of prn medications was not consistently documented;

Description: A licensee must assess each person in care on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.

Corrective Actions Required: Ensure that each person in care has been assessed to determine the risk that the person in care may leave the community care facility without notification of an employee.

Corrective Actions Taken By Licensee:

Actions Required By Licensing:

To Be Corrected By: March 16, 2023

Observations: Licensing reviewed the records of persons in care and they did not contain an assessment of risk for leaving the community care facility without notification of an employee.

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 16, 2023

Observations: Licensing reviewed the weight records of persons in care. There were many months without a weight record documented for persons in care.

Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.

Corrective Actions Required: Ensure that a persons in care's medication is returned to the pharmacy if the expiry date has passed.

Corrective Actions Taken By Licensee:

Actions Required By Licensing:

To Be Corrected By: March 16, 2023

Observations: Licensing inspected the medication storage cabinets. There were several expired medications located in the cabinets.