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

Corrective Actions Required: Ensure that all rooms and common areas are maintained 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: March 15, 2024

Observations: This contravention was carried over from the Routine Inspection dated May 16, 2022. On this date Licensing was informed that the project for installing wall boards throughout the facility was still ongoing.

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: March 15, 2024

Observations: This contravention was carried over from the Routine Inspection dated May 16, 2022. On this date Licensing observed staff files and noted that not all staff files had completed job performance reviews. The manager stated they were working on updating all staff performance reviews and were aiming to have completion in the spring 2024.

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

Corrective Actions Required: Ensure employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 15, 2023

Observations: Licensing observed the staff sign off sheet for medicated creams for December 13, 2023 and there were four persons in care with creams that were not signed for by staff.

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 all persons in care are weighed at least once a month.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 30, 2023

Observations: Licensing observed 12 persons in care weights over the last six months and 7 persons in care had missing weights.

Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.

Corrective Actions Required: Ensure that person in care's medication is returned to the dispensing pharmacy if expired.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 15, 2023

Observations: Licensing observed 30 packages of medications that expired in June 2023 and October 2023 in the medication cart. There were also two contingency medications expired and one expired inhaler in the medication cart.