Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited two bedrooms of person in care. One bedroom had a screen installed in the window. One bedroom had repairs completed to the damage on the baseboards.

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: character references in respect of the person

Corrective Actions Required: Licensing audited seven employee files and all files included a record of character references checked.

Corrective Actions Taken By Licensee:

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

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited seven employee files and all files included a record of immunization and tuberculosis.

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: Ensure that all employees comply with the policy 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: June 14, 2023

Observations: Licensing audited the bedrooms of four person in care on the second floor and observed multiple medications in three bedrooms not labelled by the pharmacy. Licensing audited the Medication Administration Records and observed medications not signed or coded for on May 31 and June 2, 2023. Licensing audited the Narcotic Count Record and observed the second staff signature missing on May 25.

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

Corrective Actions Required: Licensing audited two employee files and both files included a record of criminal record check.

Corrective Actions Taken By Licensee:

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

To Be Corrected By:

Observations:

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 each person in care has a record of the following: (b) in the case of an adult, the consent for that person in care to be admitted or to continue to be accomodated 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.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 7, 2023

Observations: Licensing audited the records of seven person in care. One person in care had consent to admission signed by the person in care's daughter, when the person in care was deemed capable. One person in care did not have a record of consent to admission.

Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: each assessment report, if any, provided under section 22 (1) (c) of the Health Care Consent Regulation.

Corrective Actions Required: Ensure a record is kept for each person in care, of each assessment report, if any, provided under Section 22(1)(c) of the Health Care Consent Regulation.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 7, 2023

Observations: Licensing audited the records of seven person in care. Three person in care who were deemed incapable, did not have a incapability assessment completed.

Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the care plan's of three person in care. All three care plan's included a fall prevention plan that addressed a plan for follow up to falls suffered.

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

To Be Corrected By:

Observations: