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 staff are complying with the 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: January 25, 2024

Observations: Licensing observed the Personalized Live Well Plan for staff to sign regarding prescription creams for persons in care. There were multiple missed staff signatures for multiple persons in care for the month of October and November 2023, which was required by MSAC policies.

Description: If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.

Corrective Actions Required: Ensure care plans are made within 30 days of admission.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 25, 2024

Observations: Licensing reviewed five person in care care plans and five care plans were incomplete and did not have interventions included in the care plan.

Description: Clear and up to date records of immunization status kept for each person in care

Corrective Actions Required: Ensure clear and up to dated records of immunizations status kept for persons in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 25, 2024

Observations: Licensing reviewed five person in care charts and five charts did not have 2023 immunization status records. The nurse stated influenza clinic occurred in October and COVID booster occurred December 11, 2023.

Description: A care plan must include all of the following: a recreation and leisure plan

Corrective Actions Required: Ensure care plan have a recreation and leisure plan.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 25, 2024

Observations: Licensing reviewed five person in cares care plans and five care plans did not have a recreation and leisure plan.

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 an assessment of the nature of the risk of falling presented by the person in care

Corrective Actions Required: Ensure person in cares care plans have an assessment of the nature of the risk of falls.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 25, 2024

Observations: Licensing reviewed five person in cares care plans and five care plans did not have an assessment of the risk of falls.

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 preventing the person in care from falling

Corrective Actions Required: Ensure a person in care, who is prone to falling, has a fall prevention plan.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 25, 2024

Observations: Licensing reviewed five person in cares care plans and five care plans did not have a plan for fall prevention.

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: Ensure that persons in care who are prone to falls, have a fall care plan which includes a plan to follow up on any falls suffered.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 25, 2024

Observations: Licensing reviewed five person in cares care plans and five care plans did not have a plan to follow up on falls suffered by a person in care.