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: Ensure to obtain character references for each employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 27, 2025

Observations: Licensing audited three staff files. One employee file contained one reference.

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 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: April 27, 2025

Observations: Licensing audited the medication cabinet and Medication Administration Record (MAR) for persons in care. One medication was signed for as administered by staff but remained in the medication roll and there was a documentation discrepancy noted on the CBD oil count.

Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.

Corrective Actions Required: Ensure that a person in care's medication is returned to the pharmacy if the date of expiry has passed.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 27, 2025

Observations: Licensing audited the medication cabinet and found two expired medications.