Description: A licensee must do all of the following: ensure that policies are implemented by employees.

Corrective Actions Required: Ensure employees implement all policies.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 5, 2022

Observations: Licensing audited two person in care's medications. One person in care required monthly Narcotic counts as per the policy, which were not completed for May, July, August, September, October, November and December 2021 and January, February and March 2022. Two persons in care had PRN medication cards which were not signed or coded for, on the back of the card, as required by the policy.

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 all persons in care are weighted monthly.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 5, 2022

Observations: Licensing audited two person in care's weights and both persons in care had weights missing for May, July, December 2021 and February, 2022.

Description: Licensees that provide care to persons who are at risk of an opioid drug overdose must obtain and maintain a supply of Naloxone and associated supples for safe administration for emergency use in the event that a person in care suffers from a drug overdose.

Corrective Actions Required: Ensure there is a supply of Naloxone and associated supplies for safe administration for emergency use in the event that a person in care suffers from a drug overdose.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 5, 2022

Observations: Licensing audited two persons in care's medications. One person in care had Narcotics on site, which included a medication containing Codeine. The facility did not have a supply of Narcotic on site.

Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities suitable to the needs of the persons in care

Corrective Actions Required: Ensure there is an ongoing plan of recreation and leisure activities suitable to the needs of persons in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 5, 2022

Observations: Licensing audited two person in care's ongoing plan of physician, social and recreational activities. Activities were not planned and the Manager indicated they were actively working on updating this.