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: Licensing audited six employee files and all six files had a record of a recent performance evaluation.

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 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 medication administration record and all dates were signed or coded for the month of February 2024. Licensing audited three person in care's bedrooms and observed no medications not labelled by the pharmacy.

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: compliance with the Province’s immunization and tuberculosis control programs,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited six employee files and all six files had a record of immunization and TB.

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

To Be Corrected By:

Observations:

Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited five person in care's charts and all five had a record of consent to admission.

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 plan to address if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the care plan's of three person in care who lived in Memory Care and all three had a plan for environmental restraint for living on a secure unit.

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

To Be Corrected By:

Observations:

Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,

Corrective Actions Required: Ensure each person in care is weighed at least once each month.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 9, 2024

Observations: Licensing audited six person in care's charts and four charts were missing a record of weight for multiple months.

Description: A licensee must keep the following records in respect of each employee: character references,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited six employee files and all six files had a record of character references obtained.

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

To Be Corrected By:

Observations: