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 all 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: November 24, 2023

Observations: Licensing audited the medication administration record for two person in care. Medications were not signed or coded for by staff on October 2, 3, and 4, 2023 for 2100hrs medication for one person in care. PRN results were not recorded on October 3, 2023 for one person in care. Licensing audited the medication cupboard and one antibiotic ointment was not labelled by the pharmacy.

Description: A licensee must ensure that each menu provides for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada’s Food Guide,

Corrective Actions Required: Ensure that each menu provides for each day, a nutritious morning, noon and evening meal.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: November 24, 2023

Observations: Licensing audited the menu plan for each day and observed on five days a week lunch meal only stated "bagged lunch" and had not included what was included in the bag lunch.

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 a person's in care medication is returned to the dispensing pharmacy if the expiry date on the medication had passed.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: November 24, 2023

Observations: Licensing audited the medication cupboard and observed an antibiotic ointment had expired.

Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities suitable to the needs of the persons in care

Corrective Actions Required: Ensure there is ongoing planned program of physical, social, and recreational activities suitable to the needs of the persons in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: November 24, 2023

Observations: Licensing audited the activity schedule for two person's in care. One person in care did not have any activities scheduled for Tuesday or Thursday and had no activities scheduled in the afternoons.