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

Corrective Actions Required: Ensure to keep the criminal records check results for each employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 15, 2026

Observations: Licensing reviewed staff files. The Licensee was unable to locate criminal record check results for staff.

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: Ensure to keep the following records in respect of each employee: compliance with the Provinces immunization and tuberculosis control program.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 15, 2026

Observations: Licensing audited staff files. The Licensee was unable to produce evidence of Tuberculosis testing or immunization records.

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: Ensure that is a person in care is admitted to a community care facility for more than 30 days, there is a care plan for the person in care made in accordance with this section within 30 days of admission.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 22, 2026

Observations: Licensing reviewed two person in care's care plans. One person in care, who was admitted to the facility in September 2025, did not have a care plan.

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: 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 Taken By Licensee:

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

To Be Corrected By: April 15, 2026

Observations: Licensing audited the care plans of persons in care. The care plans were last reviewed two to five years prior.

Description: A licensee must appoint a medication safety and advisory committee consisting of at least the following persons: the supervising pharmacist appointed under subsection (2)

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing was informed that the new pharmacist at the new pharmacy has been to inspect the medication cabinet and is now aware they are a prescribing pharmacy for a community care facility and that policies are required for the MSAC.

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

To Be Corrected By:

Observations: