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:

Corrective Actions Taken By Licensee: Licensee submitted a copy of the one staff updated criminal record check on June 6, 2024.

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 observed the medication administration sheets dated June 2024 for four persons in care and PRN [ prescribed as needed] medication creams were signed for by staff.

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

To Be Corrected By:

Observations:

Description: A licensee of a community care facility with more than 24 persons in care must develop, with the assistance of a dietitian, a nutrition plan for each person in care.

Corrective Actions Required: Ensure that a nutrition care plan is developed with the assistance of a dietitian.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 11, 2024

Observations: Licensing reviewed three persons in care's nutrition plans who were admitted January 26, March 3 and April 4, 2024, when the facility did not have a dietitian. All three nutrition plans were developed by the Director of Health and Wellness.

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: Ensure that the facility is operated in a manner that promotes the health, safety and dignity of persons in care. Specifically, that agreed upon conditions related to exemptions are followed.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 28, 2024

Observations: Licensing was notified by the Manager that the Director of Culinary Services did not complete the Canadian Society of Nutrition Management (CSNM) program and did not obtain a diploma which was part of the approved exemption conditions dated October 26, 2022. This approved exemption expires on September 24, 2024. Licensing was notified that the education funding was removed for the Director of Culinary Services.