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

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

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 18, 2023

Observations: Licensing observed one bedroom of a person in care with significant wall damage.

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: Ensure that the performance of each employee is reviewed regularly.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 18, 2023

Observations: Licensing audited 14 staff files. 11 staff files had performance reviews dated 2021, one performance review was dated 2015, one performance review was dated 2009, and one staff was missing a performance review.

Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the narcotic counts on the first and second floor and observed all narcotic counts had been completed and signed for during the month of May 2023.

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

To Be Corrected By:

Observations:

Description: A licensee must keep the following records in respect of each employee: criminal record check results,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing reviewed one employee file that included a Criminal Record Check that was recently completed and expires in April 2028.

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

To Be Corrected By:

Observations:

Description: Clear and up to date records of immunization status kept for each person in care

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited eight care records for persons in care and observed all records included a record of immunization status.

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 eight care plans for persons in care and all care plans 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 licensee must ensure that all medications in the community care facility are safely and securely stored.

Corrective Actions Required: Ensure that all medications in the community care facility are safely and securely stored.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 18, 2023

Observations: Licensing audited eight bedrooms of persons in care and observed medicated creams not securely stored in multiple bathrooms of persons in care.

Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy the person in care is no longer taking the medication

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the medication fridge on the first and second floor and did not observe any medications that were no longer being used by persons in care.

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

To Be Corrected By:

Observations: