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

Corrective Actions Required: Licensing observed the Personalized Live Well Plan for staff to sign regarding prescription creams for persons in care for January 2024 and signatures were completed.

Corrective Actions Taken By Licensee:

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

To Be Corrected By:

Observations:

Description: If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing reviewed five care plans that were complete within 30 days of admission.

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: Ensure clear and up to dated records of immunizations status kept for persons in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 25, 2024

Observations: Licensing reviewed five person in care charts and five charts did not have 2023 immunization status records. The nurse stated influenza clinic occurred in October and COVID booster occurred December 11, 2023.

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

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing observed the recreation binder in the nursing station that included all persons in care's recreation care plans.

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 reviewed five care plans for persons in care and all five care plans had an assessment of the risk of falls.

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 reviewed five care plans which addressed fall prevention for persons in care at risk for falls.

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 reviewed five care plans and all five care plans for persons in care had a plan to follow up on falls suffered.

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

To Be Corrected By:

Observations: