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 that all employees have evidence of compliance with the Province's immunization and tuberculosis control programs.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 24, 2024

Observations: Licensing audited three employee files. Two employee files did not have a record of immunization.

Description: A licensee must ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C,

Corrective Actions Required: Ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 10, 2024

Observations: Licensing audited three employee files. All three employee files did not have a valid first aid certificate. The Director of Care (DOC) stated they were not sure if there was always a staff on shift with a valid first aid certificate.

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 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: July 10, 2024

Observations: Licensing observed the electronic Medication Administration Record (eMAR) for July 3 to July 9, 2024. One person in care did not have two medications signed or coded for by staff on one date.

Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable

Corrective Actions Required: Ensure that each person in care has a consent for that person in care to be admitted or to continue to be accommodated in accordance of the Health Care (Consent) and Care Facility (Admission) Act.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 24, 2024

Observations: Licensing audited one person in care's file. The person in care did not have a consent to admission in accordance with the Health Care (Consent) and Care Facility (Admission) Act.

Description: A care plan must include all of the following: an oral health care plan

Corrective Actions Required: Ensure that each care plan includes an oral health care plan.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 24, 2024

Observations: Licensing reviewed one person in care's care plan. There was no individualized oral health care plan for the person in care.

Description: A licensee must keep the following records in respect of each employee: criminal record check results,

Corrective Actions Required: Ensure that all employee files have criminal record check results.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 10, 2024

Observations: Licensing audited three employee files. Two employee files had an expired criminal record check on file.