Description: A licensee must do all of the following: ensure that policies are implemented by employees.

Corrective Actions Required: Ensure policy implementation by employees.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 20, 2022

Observations: Licensing audited three person in care's medications and medication administration records. One person in care prescribed cannabis oil required monthly documented medication counts, as per the medication policy. Medication counts for the cannabis oil were missing for November and December 2021and January 2022.

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 medications are returned to the pharmacy if expired.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 20, 2022

Observations: Licensing audited the facility's medication cabinet and observed the Naloxone medication had an expiry date of June 2021.

Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities suitable to the needs of the persons in care

Corrective Actions Required: Ensure there is an ongoing planned program of physical, social and recreational activities are offered designed to meet the needs of the persons in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 20, 2022

Observations: Licensing audited four person in care's calendars of ongoing planned programs of physical, social and recreational activities. There was minimal ongoing activities documented for each person in care for January 2022.