Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee demonstrates the competence required for the duties to which the employee is assigned.

Corrective Actions Required: Ensure the performance of each employee is reviewed regularly to ensure the employee demonstrates the competence required for the duties assigned.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 25, 2024

Observations: This item has been carried forward from Routine Inspection 1C7A7478-B801-4FFC-9DEB-1E97D3642767 dated September 12, 2022. Licensing reviewed 10 staff files. None of the files had current performance reviews completed. The facility policy stated performance reviews are completed annually.

Description: Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the medical practitioner or nurse practitioner responsible for the health of the person in care.

Corrective Actions Required: Ensure that an agreement to use the restraint given in writing by the medical practitioner or nurse practitioner responsible for the health of the person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 12, 2023

Observations: This item has been carried forward from Routine Inspection 1C7A7478-B801-4FFC-9DEB-1E97D3642767 dated September 12, 2022. Licensing reviewed 10 person in care's files and found one person with an active restraint in place, did not have any restraint agreement on file.

Description: A licensee must ensure that each menu provides for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada’s Food Guide,

Corrective Actions Required: Ensure that each menu provides for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide,

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 1, 2023

Observations: This item has been carried forward from Routine Inspection 1C7A7478-B801-4FFC-9DEB-1E97D3642767 dated September 12, 2022. Licensing toured facility and observed the menu posted in dining room. The menu did not include breakfast.

Description: A licensee must ensure that each menu provides for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada’s Food Guide,

Corrective Actions Required: Ensure that each menu provides for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 1, 2023

Observations: This item has been carried forward from Routine Inspection 1C7A7478-B801-4FFC-9DEB-1E97D3642767 dated September 12, 2022. Licensing reviewed the menu posted in the dining room which did not include snacks.

Description: A licensee must keep a record in respect of each person in care showing the following information: all money, valuables and other things held by the licensee that were returned to a person in care, or the parent or representative of a person in care, when the person in care left the community care facility or died.

Corrective Actions Required: Ensure a record in respect of each person in care is kept showing the following information: all money, valuables and other things held by the licensee in trust or safekeeping for persons in care or the parent or representative of a person in care, when the person in care leaves the community care facility or dies.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 12, 2023

Observations: Licensing reviewed 10 person in cares files and no persons in care had a record of money, valuables and other things held by the licensee in trust or safekeeping.