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. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On March 21 and April 23, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: A staff member was removed from administering medication and went through a review of medication administration competency in detail, and all staff were required to undergo medication competency testing yearly. The corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 2, 2025

Observations: Regarding intake February 3, 2025. Through the investigation process, Licensing determined that employees had not follow medication safety and advisory committee policies.

Description: A licensee must ensure that a person in care is not, while under the care or supervision of the licensee subjected to any of the following types of abuse or neglect, as described in section 1 of Schedule D: emotional abuse

Corrective Actions Required: Ensure that a person in care is not, while under the care or supervision of the licensee, subjected to emotional abuse. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On March 21 and April 23, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that a staff member's employment was terminated effective April 22, 2025, all staff were required to review policies on abuse of persons in care by March 31, 2025. The corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 2, 2025

Observations: Regarding intake February 3, 2025. Through the investigation process, Licensing determined that a person in care was subjected to emotional abuse.

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. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On March 21 and April 23, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: All staff were required to review policies on incident reporting prior to March 31, 2025 and ongoing training on reportable incidents would be a standing agenda item on all staff meetings. The corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 2, 2025

Observations: Regarding intake February 3, 2025. Through the investigation process, Licensing determined that the medical health officer was not informed of a reportable incident.