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 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: October 28, 2021

Observations: Licensing audited the electronic Medication Administration Record and noted that on October 25, 2021 ten persons in care's medications were not signed for as being administered. As per the medication safety and adivsory policies all medications must be signed as administered.

Description: Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer

Corrective Actions Required: Ensure that if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: November 28, 2021

Observations: Licensing reviewed the facility incident reports. There was multiple incident reports not submitted immediately.

Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care

Corrective Actions Required: Ensure that in the case of a person in care who received a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care is implemented.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: November 4, 2021

Observations: Licensing audited six person in care's care plans. One care plan did not have a plan to address following up on falls.

Description: A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.

Corrective Actions Required: Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: October 28, 2021

Observations: Licensing audited six person in care's care plans. One care plan indicated hourly documented elopement monitoring and one care plan indicated hourly documented monitoring of a restraint. Licensing observed the monitoring documentation and noted multiple dates and times of the safety checks not documented.

Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,

Corrective Actions Required: Ensure that each person in care is weighed at least once each month.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 28, 2022

Observations: Licensing audited six person in care's weight records. Three persons in care records had monthly weights missing.