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 water accessible to persons in care is not heated to more than 49 degrees Celisus.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 22, 2024

Observations: Licensing measured the water temperature in five persons in care bathrooms which all 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 is to be submitted to Licensing by March 22, 2024. Full compliance will not be achieved until the plan has been implemented and completed.

Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: a criminal record check for the person

Corrective Actions Required: Ensure all staff have a current criminal record check on file.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 22, 2024

Observations: Licensing reviewed twelve staff files and one staff file did not have a current criminal record check.

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: March 22, 2024

Observations: Licensing observed the medication administration sheets for medication creams, for ten persons in care, dated March 2024. All ten persons in care did not have the medicated creams signed for by staff. The Director of Wellness stated staff should be signing the medication administration sheets for administration of medication creams. Licensing observed a missed staff signature for March 18, 2024, 1700 hour medications for one person in care.

Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year

Corrective Actions Required: Ensure policies and procedures are reviewed and revised if necessary at least once each year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 21, 2024

Observations: Licensing observed the polices with a different facility name and the policies had not been reviewed and if necessary revised at least once each year.

Description: A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,

Corrective Actions Required: Ensure the licensee operates the facility in a manner that promotes the health, safety and dignity of persons in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 29, 2024

Observations: Licensing reviewed five person in care bathing charting for February and March 2024 and one person in care did not have any bathing charting in the months of February and March 2024. Staff stated that person in care did receive baths.

Description: A licensee must ensure that all medications in the community care facility are safely and securely stored.

Corrective Actions Required: Ensure that all medications are safely and securely stored.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 22, 2024

Observations: Licensing observed a medicated cream in person in care's bathroom not securely stored.