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:

Corrective Actions Taken By Licensee:

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

To Be Corrected By:

Observations: Licensing reviewed ten staff files and observed one staff file did not have a criminal record check on file.

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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs.

Corrective Actions Required:

Corrective Actions Taken By Licensee:

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

To Be Corrected By:

Observations: Licensing reviewed ten staff files and five staff files did not obtain evidence of compliance with the Province's immunization and four staff files did not have evidence of compliance with the TB program.

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 continues to meet the requirements of this regulation,

Corrective Actions Required:

Corrective Actions Taken By Licensee:

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

To Be Corrected By:

Observations: Licensing reviewed ten staff files and one staff file had a performance review dated May 2019. The was another staff file that did not have any performance review.

Description: A licensee must do all of the following: ensure that policies are implemented by employees.

Corrective Actions Required:

Corrective Actions Taken By Licensee:

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

To Be Corrected By:

Observations: Licensing reviewed five persons in care's bathing records for November and December 2022 and two persons in care's records had no entries for baths.

Description: A licensee must ensure that meals are provided by ongoing room tray service, if by ongoing room tray service, if indicated in the care plan of a person in care,

Corrective Actions Required:

Corrective Actions Taken By Licensee:

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

To Be Corrected By:

Observations: Licensing reviewed six care plans and two care plans did not note the ongoing room tray service. Staff stated that the two persons in care eat all meals in their rooms.

Description: A licensee must ensure that each menu provides for substitutions to be made that are from the same food group and have a similar nutritional value.

Corrective Actions Required:

Corrective Actions Taken By Licensee:

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

To Be Corrected By:

Observations: Licensing talked to the Director of Culinary who stated they did not have a substitution list made from the same food group and have a similar nutritional value.

Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan

Corrective Actions Required:

Corrective Actions Taken By Licensee:

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

To Be Corrected By:

Observations: Licensing reviewed six care plans and four care plans had recreation/ leisure plans dated 2020, September and October 2021.