Description: A licensee must do all of the following: ensure that policies are implemented by employees.

Corrective Actions Required: Ensure policies are implemented by employees.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 5, 2023

Observations: Licensing audited the narcotic counts and observed narcotics were not counted on November 13, 14 and Dec 4, 2022. The narcotic count policy stated it was required to be counted once per shift. The Manager stated they were in the process of discussing the counts with the pharmacy.

Description: Clear and up to date records of immunization status kept for each person in care

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited one person in care's record which included a record of immunization status kept.

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

To Be Corrected By:

Observations:

Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited two person in care's records and both records included documentation that they complied with the tuberculosis control program.

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

To Be Corrected By:

Observations:

Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited three person in care's charts which included consent in writing from the person in care or parent or representative of the person in care, to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.

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: an oral health care plan

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited one person in care's care plan which included a oral health care plan.

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 recreation and leisure plan

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited two person in care's care plans and both care plans included recreation and leisure 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 a plan for following up on any falls suffered by a person in care

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited one person in care's care plan which included a fall prevention plan, addressing a plan for following up on any falls suffered by the person in care, who was identified as prone to falling.

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

To Be Corrected By:

Observations:

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:

Corrective Actions Taken By Licensee: Licensing audited one person in care's care plan that was updated December 2022 and next due for a review in June 2023.

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

To Be Corrected By:

Observations: