Description: A Licensee must do all of the following: operate the community care facility in a manner that will promote the health, safety and dignity of persons in care.

Corrective Actions Required: Ensure the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care. Action/s Required by Licensing: Follow Up Inspection required.

Corrective Actions Taken By Licensee:

Actions Required By Licensing:

To Be Corrected By: September 3, 2021

Observations: Licensing observed the greeter at the front entrance was not wearing eye protection. The greeter was not actively screening people who came into the building. Temperatures were taken, but no screening questions asked. People coming on site are to sign in and a required to put "Yes" or "No" related to screening questions. Screening questions are posted behind the greeter station, not near where persons sign into the building. Licensing spoke with leadership on site who stated this will be corrected by the end of the day.

Description: A licensee must keep, for each person in care, a medication administration record showing the date, amount and time at which the medication was administered.

Corrective Actions Required: Ensure that for each person in care, a medication administration record showing the date, amount and time at which the medication was administered. Action/s Required by Licensing: Follow Up Inspection required.

Corrective Actions Taken By Licensee:

Actions Required By Licensing:

To Be Corrected By: September 17, 2021

Observations: Licensing reviewed medication administration records for several persons in care on the eMAR point click care system. Many medications had not been signed as administered in the medication administration record for the month of August 2021.

Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care

Corrective Actions Required: Ensure that each care plan is reviewed and modified if there is a substantial change in the circumstances of the person in care. Action/s Required by Licensing: Follow Up Inspection required.

Corrective Actions Taken By Licensee:

Actions Required By Licensing:

To Be Corrected By: September 17, 2021

Observations: Licensing reviewed four care plans, specifically reviewing wound care. One care plan did not contain any wound care information for a person in care who has an active wound.