Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair

Corrective Actions Required: Ensure that all rooms and common areas are maintained in good state of repair

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 19, 2024

Observations: Licensing toured 5 bedrooms of persons in care and observed wall damage in two bedrooms.

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 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: April 19, 2024

Observations: Licensing audited the medication cupboards and observed one narcotic that did not have an expiry date. Licensing audited the medication administration records and on four dates in March 2024, there was no signature or coding for one medication for one person in care by staff.

Description: A licensee must keep the following records in respect of each employee: character references

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited five employee files and all five files included a record of character references.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

Description: A care plan must include all of the following: an oral health care plan

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the care plan's of four person in care and all four care plan's had a plan that addressed oral health.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

Description: A care plan must include all of the following: a nutrition plan that specifies the nutrition to be provided to the person in care, including the requirements of any therapeutic diets

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the care plan's of four person in care and all four care plan's included a nutrition plan.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

Description: A care plan must include all of the following: a recreation and leisure plan

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the care plan's of four person in care and all four care plan's included a recreation and leisure plan.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

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 an assessment of the nature of the risk of falling presented by the person in care

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the care plan's for four persons in care and all four care plan's included a fall prevention plan addressing the assessment of risk of falling.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

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 preventing the person in care from falling

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the care plan's of four persons in care and all four care plan's included a fall prevention plan.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

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:

Corrective Actions Taken By Licensee: Licensing audited the care plan's of four persons in care and all four care plan's included a fall prevention plan which addressed a plan for following up on any falls suffered.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations: