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 that policies and procedures are reviewed and if necessary, revised at least once each year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 4, 2022

Observations: Licensing reviewed the facility policies which were last reviewed in 2016, 2017 and 2019.

Description: A licensee must ensure that each menu provides for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada’s Food Guide,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing observed the facility menu posted at the facility which included two snacks.

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

To Be Corrected By:

Observations:

Description: If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must notify a medical health officer

Corrective Actions Required: Ensure that the Licensee notifies a medical health officer immediately of any change in the information provided under section 7 [applying for a licence] (3)If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (b)replace the manager, either by hiring a person who, or using a hiring process that, is approved in writing by the medical health officer.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 26, 2022

Observations: On March 3, 2022, Licensing was notified that a new Manager started in the role effective February 28, 2022. Licensing provided the Licensee with the documentation to propose a new Manager on March 3, 2022, April 5, 2022 and April 21, 2022 with no response.

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: Ensure that if a person in care may be prone to falling, they have a fall prevention plan, which addresses a plan to follow upon falls suffered by the person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 11, 2022

Observations: This item had been carried over from Routine Inspection HOBN-C3LQAM dated June 2, 2021. Licensing audited one person in care's care plan who was at risk for falls who had not had a fall prevention plan that addressed a plan to follow up on falls suffered.

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 two person in care's care plans who were at risk for falls. Both persons in care had a plan to prevent falls in their care 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 preventing the person in care from falling

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited two person in care's care plans who were at risk for falls. Both persons in care had a follow up to falls addressed in their care 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 two person in care's care plans who were at risk for falls. Both persons in care had a follow up to falls addressed in their care plan.

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

To Be Corrected By:

Observations:

Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities suitable to the needs of the persons in care

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing observed an ongoing recreation calendar posted at the facility. Licensing confirmed with the Community Nurse Supervisor that staff assisted persons in care with activities.

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

To Be Corrected By:

Observations: