Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.

Corrective Actions Required: Ensure that water accessible to a person in care, from any source, is not heated more than 49 degrees Celsius.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 22, 2022

Observations: Licensing tested the water temperature in the tub room and the temperature read 54 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. A plan for corrective action plan was submitted to Licensing by the Manager on December 15, 2022. The plan: the Manager contacted BC Housing to come on site and adjust the temperature, and the Manager was going to tape the sink to inform persons in care and staff to not use. Full compliance will not be achieved until the plan has been implemented and completed..

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 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: January 15, 2023

Observations: Licensing audited two person in care's medication administration records and monthly narcotic counts. One person in care did not have a medication signed or coded for on December 6 and 11, 2022 at 20:00 p.m. Two persons in care did not have monthly narcotic counts, as required by the medication policies, for March, May and June 2022.

Description: A licensee must keep the following records in respect of each employee: character references

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing received a copy of one character reference in respect of one employee.

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

To Be Corrected By:

Observations:

Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care

Corrective Actions Required:

Corrective Actions Taken By Licensee: Ensure the community care facility is operated in a manner that promotes the health, safety and dignity of persons in care. Specifically, complying with the terms and conditions on the licence.

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

To Be Corrected By: January 15, 2023

Observations: Licensing observed a condition on the licence, stating a Registered Nurse was on site minimum 10 hours per month. The facility currently has a Licenced Practical Nurse in that role and are operating in non-compliance with the condition on the licence. The Licensee Contact submitted a plan to the Licensing Program regarding the condition on the licence on August 24, 2022. The Licensee Contact requested the condition on the licence be removed which is pending.

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 person in care's medications are returned to the dispensing pharmacy if the expiry date has passed.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 15, 2023

Observations: Licensing audited the facility's medication cabinet and observed a naloxone medication as dated April 2022.